-
pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module1/module1_tools.docx
March 01, 2013 - . † Adverse outcomes (a) Firm mattresses; low beds; appropriate chair heights and depths for easy transfer … and falls prevention) simultaneously and found an overall positive effect on the development of any adverse … However, Oliver and colleagues also note “so little empiric evidence on adverse effects of fall prevention … Fewer adverse events as a result of the SAFE or SORRY? … events.
-
pcmh.ahrq.gov/patient-safety/news-events/psaw-2019/index.html
July 01, 2022 - Patients and Families
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events … https://www.ahrq.gov/patient-safety/news-events/psaw-2019/index.html
-
pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/medicinelist-patient-flier-final508.pdf
April 12, 2018 - .
■ Answer your questions.
1 in 9
emergency
department admissions
are related to an
adverse drug
-
pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module8/module8-organizational-learning-sustainability.pptx
August 20, 2015 - improvement metrics, which allows for improvement of CANDOR processes, and prevention of similar harm events … Over time, the organization must continue to encourage frontline staff to report CANDOR events and other … adverse patient events by promoting transparency and a fair and just culture. … Celebrating staff for reporting CANDOR (and other) events, such as near misses and unsafe conditions. … Encourage your Team Leads to discuss actual CANDOR events to drive home important lessons.
-
pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety_facguide.pdf
May 01, 2017 - L&D unit staff are
able to focus on patient care and have
confidence that untoward events (change in … order; this is done to ensure
that no steps are missed rather than to
dictate a rigid sequence of events … Fostering a culture that supports
debriefing by the clinical team
immediately after a near miss, an
adverse … • Having a process in place to review
severe maternal or neonatal morbidity
and mortality events … Factors to consider—
o Unit and malpractice claims data
suggesting adverse events or near
misses
-
pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/improving/improving.pptx
May 01, 2017 - for Ambulatory Surgery
6
Studies show that communication failures are the cause of 80 percent of adverse … for the entire team
Cards were placed in every operating room
Reduced wrong-site surgeries and other adverse … events
Increased staff morale
Reduced nursing turnover
4Shepard S. … Ensures all team members are on the same page
Confirms critical information
Provides a place to discuss adverse … or potentially adverse events that occurred
Facilitates discussion of how to stop problems from reoccurring
-
pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/medicinelist-slides-508.pdf
April 10, 2018 - • Adverse drug events
• Unsafe medicine issues
• Medicine adherence
• Satisfaction
• Reported use … We will use several measures to evaluate effectiveness:
How many adverse drug events occur pre- and
-
pcmh.ahrq.gov/sites/default/files/wysiwyg/action-alliance/CMS-Aug-23-board-session.pdf
August 22, 2023 - The board’s tracking of adverse events and delineated types of errors (including near misses) -
focus … ensure they have/are part of QAPI efforts where
appropriate and understand how to identify and report events … complaints in
cardiology and cardiac
surgery
• Patient mortality triple
the norm and rise in
adverse … events and
claims (often lagging
indicators)
• Patient complaints
• Culture of Non-
transparency … • Could a department hide
embarrassing events from
management and the board?
-
pcmh.ahrq.gov/data/infographics/index.html
March 01, 2024 - Family Premiums for Employer-Sponsored Health Insurance
Growing Pain of Spinal Stenosis
Adverse … Drug Events Occurring in U.S.
-
pcmh.ahrq.gov/teamstepps/instructor/essentials/implguide.html
November 01, 2018 - supporting the need for a TeamSTEPPS Intervention could originate from a variety of sources, including adverse … Available organizational data, (e.g., adverse event and near miss reports, AHRQ Patient Safety Culture … so that facilities may also use the Guide to develop TeamSTEPPS Action Plans in response to sentinel events
-
pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_4_PPT_508.pdf
May 22, 2013 - • Nearly 20 percent of patients experience an adverse event
within a month of discharge, of which ¾ … could be prevented
• Common complications post-discharge are adverse drug
events, hospital-acquired
-
pcmh.ahrq.gov/funding/policies/nofoguidance/index.html
January 01, 2024 - Surveillance, measurement, detection, and reporting of patient safety events. … Determination of the clinical efficacy and effectiveness of preventive interventions, including unintended adverse
-
pcmh.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2014-materials/teamstepps-monthly-webinar-dec2014.pptx
January 01, 2014 - 1 05.2 Page ‹#›
TeamSTEPPS®
TeamSTEPPS for Patients
Slide ‹#›
11
Research Aims
Identify L&D events … (Mutual Support)
Adverse events may be reduced by maintaining an information exchange with patients and … TEAMSTEPPS 05.2
Mod 1 05.2 Page ‹#›
TeamSTEPPS®
TeamSTEPPS for Patients
Slide ‹#›
Upcoming TeamSTEPPS Events
-
pcmh.ahrq.gov/news/blog/ahrqviews/achieve-health-equity.html
August 01, 2021 - this section
News
Newsroom
Blog
AHRQ Views
Newsletter
Events … Clearly, the COVID-19 pandemic has further illuminated the scale and adverse impacts of this problem,
-
pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module10/igmeasure.pdf
January 01, 2004 - PSIs
are a set of measures that provide information about potential in-
hospital complications and adverse … events (outcomes) following
surgeries, procedures, and childbirth. … The PSIs can be used to help hospitals identify potential adverse
events that might require further … also include
indicators for complications occurring in-hospital that may
represent patient safety events … Such events can be mitigated
with the implementation of TeamSTEPPS tools and strategies.
-
pcmh.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2017-materials/TS_OBC_Webinar_Plitt_FINAL.pptx
January 01, 2017 - patients with a diagnostic error
Paid medical liability claims (Bishop, et al., 2011):
Half related to events … When patients have difficulty with these self-management activities, they are at risk for adverse events
-
pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/infographicposter-final508_0.pdf
July 12, 2018 - diagnostic errors
were a chief concern
in outpatient visits
1 in 9
ED admissions
are related to an
adverse
-
pcmh.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2019qdr-final-es-cs061721.pdf
December 01, 2020 - Importance of Patient Safety
Mortality
Prevalence
Cost
Findings on Patient Safety
Improving Trend: Adverse … Drug Events With Heparin and Factor Xa
Improving Trend: Inpatient Adverse Drug Events With Anticoagulants
-
pcmh.ahrq.gov/news/blog/ahrqviews/uneven-impact-covid19.html
December 01, 2021 - this section
News
Newsroom
Blog
AHRQ Views
Newsletter
Events
-
pcmh.ahrq.gov/news/blog/ahrqviews/addressing-historical-racism.html
April 01, 2021 - this section
News
Newsroom
Blog
AHRQ Views
Newsletter
Events