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Showing results for "adverse events".
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301. Improving-Facnotes (doc file)
     pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/improving/improving-facnotes.docx
     May 01, 2017 - Studies have found that communication failures are the cause of up to 80 percent of operating room adverse … events. … Furthermore, lack of communication has resulted in serious patient safety events such as teams performing … Use of the briefing card led to a drop in wrong-site surgeries and other adverse events. … Slide 43 SAY: Studies show that many times when adverse events occur in the surgical environment,

302. Hospital Language Services: Quality Improvement and Performance Measures (pdf file)
     pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Regenstein_54.pdf
     May 08, 2008 - one study, language barriers are associated with 1 2 an increased risk for serious medical events … during pediatric hospitalizations.12 For patients with LEP, adverse events occurring during hospitalization … Are language barriers associated with serious medical events in hospitalized pediatric patients? … Language proficiency and adverse events in U.S. hospitals: A pilot study.

303. Potentially Preventable Readmissions: Conceptual Framework To Rethink the Role of Primary Care: Final Report (pdf file)
     pcmh.ahrq.gov/sites/default/files/wysiwyg/patient-safety/rev-finalreport-update-2021.pdf
     January 01, 2021 - Care 1 INTRODUCTION High rates of readmissions are a major patient safety problem associated with adverse … events such as prescribing errors and misdiagnoses of conditions in the hospital and ambulatory care … As the evidence base for reducing adverse events and readmission from the primary care setting grows … role of the primary care team in improving quality and safety for patients and reducing postdischarge adverse … events and potentially preventable readmissions.

304. ABCS Aspirin Treatment for Secondary and Primary Prevention ASCVD
     pcmh.ahrq.gov/sites/default/files/wysiwyg/evidencenow/heart-health/aspirin-asa-measure.pptx
     April 01, 2016 - Measure Exceptions Adverse effect, allergy, or intolerance to Aspirin and Plavix (Clopidogrel). … Ischemic Vascular Disease Secondary prevention is where the evidence is the best Reduces risk of vascular events

305. TeamSTEPPS® Teamwork Attitudes Questionnaire Manual | Agency for Healthcare Research and Quality
     pcmh.ahrq.gov/teamstepps/instructor/reference/teamattitudesmanual.html
     April 01, 2017 - safety, leadership, interpersonal interactions, attitudes toward stress, and knowledge of how to report adverse … events ( Sexton, et al., 2006 ). … Adverse events may be reduced by maintaining an information exchange with patients and their families

306. Selected Best Practices and Suggestions for Improvement (pdf file)
     pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4k_combo_psi14-dehiscence-bestpractices.pdf
     May 20, 2016 - abdominal surgeries, and is associated with significant risk of mortality between 14% and 50%.1 Other adverse … events include prolonged length of stay, subsequent surgeries and incisional herniation.2,3 • Proper

307. Selected Best Practices and Suggestions for Improvement (pdf file)
     pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4b_combo_psi05-foreignbody-bestpractices.pdf
     November 01, 2012 - foreign objects avoidable.1 • Retained foreign objects represent a serious and significant patient adverse … Chasing zero events of harm: an urgent call to expand safety culture work and customer engagement.

308. AHRQ Safety Program for Perinatal Care: Labor and Delivery Unit Safety
     pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety.pptx
     May 01, 2017 - L&D Unit Safety 30 Key Safety Elements: Learn From Defects Debrief and analyze near misses and adverse … events. … Have a process in place to review severe maternal or neonatal morbidity and mortality events. … Factors to consider: Unit and malpractice claims data suggesting adverse events or near misses related

309. Strategy 6E: Rapid Referral Programs | Agency for Healthcare Research and Quality
     pcmh.ahrq.gov/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/access/strategy6g-rapid-referral.html
     April 01, 2023 - Guidance Supplemental Items Using CAHPS Surveys CAHPS Databases Webcasts & Recent Events … possibility of delays in care, which generates greater anxiety and contributes to a greater risk of adverse

310. AHRQ Safety Program for Perinatal Care: Safe Medication Administration: Oxytocin (doc file)
     pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/medication/tool_safe-oxytocin.docx
     May 01, 2017 - parameters for provider notification and expectations for provider response ensures that signs of potential adverse … Defects (CUSP Module) Key Perinatal Safety Elements Examples Debrief and analyze near misses and adverse … events related to oxytocin use … · Unit can decide its approach to debriefing events based on seriousness of event, expertise available … Have a process in place to review severe maternal or neonatal morbidity and mortality events.

311. Module 1: Preventing Falls in Hospitals—Slide Presentation | Agency for Healthcare Research and Quality
     pcmh.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-1/slides.html
     September 01, 2017 - Patients and Families About AHRQ's Quality & Patient Safety Work Patient Safety News and Events … understanding that even small failures in safety protocols or processes can lead to catastrophic or adverse … events if action is not taken to solve the problem.

312. Improving Communication and Teamwork in the Surgical Environment Module: Facilitator Notes | Agency for Healthcare Research and Quality
     pcmh.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/improving-fac-notes.html
     May 01, 2017 - Studies have found that communication failures are the cause of up to 80 percent of operating room adverse … events. … Furthermore, lack of communication has resulted in serious patient safety events such as teams performing … Use of the briefing card led to a drop in wrong-site surgeries and other adverse events. … Voicing Concerns in the Surgical Environment Is Important Say: Studies show that many times when adverse

313. Tool 5: How To Conduct a Postdischarge Followup Phone Call | Agency for Healthcare Research and Quality
     pcmh.ahrq.gov/patient-safety/settings/hospital/red/toolkit/redtool5.html
     March 01, 2013 - Patients and Families About AHRQ's Quality & Patient Safety Work Patient Safety News and Events … Pay special attention to medicines for which the adverse consequences of taking them incorrectly are … Interventions for patients reporting feeling worse since discharge due to primary discharge diagnosis, adverse

314. Statistical Process Control:Possible Uses to Monitor and Evaluate Patient-Centered Medical Home Models | PCMH Resource Center
     pcmh.ahrq.gov/page/statistical-process-controlpossible-uses-monitor-and-evaluate-patient-centered-medical-home
     March 01, 2013 - Measure rare events. … SPC can also be used to follow occurrence of adverse events that tend to be rare, such as failure to … chart (a g-chart, where g stands for geometric distribution), evaluators can track the days between events … to provide a visual representation of the current status and progress for avoiding rare events (Wall

315. AHRQ Safety Program for Perinatal Care: Labor and Delivery Unit Safety Safe Cesarean Section (doc file)
     pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/tool_safe-csection.docx
     May 01, 2017 - Learn From Defects (CUSP Module) Key Perinatal Safety Elements Examples Debrief and analyze adverse … events related to cesarean section … · Unit can decide its approach to debriefing events based on seriousness of event, expertise available … case reviews Have a process in place to review severe maternal or neonatal morbidity and mortality events

316. Nursing Home Workplace Safety Resource List (pdf file)
     pcmh.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursing-home-workplace-safety-resources.pdf
     January 01, 2023 - page provides tips to encourage staff members to report conditions that could lead to near-misses or adverse … events.

317. TeamSTEPPS 2.0 Module 3: Communication
     pcmh.ahrq.gov/sites/default/files/wysiwyg/teamstepps/instructor/onlinecourse/tsonlinemodule3.pptx
     December 01, 2005 - * 2010 - 2012: Ineffective communication among top 13 root causes of sentinel events reported ** * ( … JC Root Causes and Percentages for Sentinel Events (All Categories) January 1995−December 2005) ** (JC … As a patient safety officer, I covered all our sentinel events, as well as any other adverse events, … which may not have been sentinel events. … We use it in our adverse event reports.

318. Care-Mgmt-Issue-Brief-No-15-0018-Ef (pdf file)
     pcmh.ahrq.gov/sites/default/files/attachments/Care-Mgmt-Issue-Brief-No-15-0018-EF.pdf
     April 01, 2015 - between different locations (e.g., from hospital to primary care) are associated with increased risks of adverse … medication events, hospital readmissions, and higher health care costs.25 Determining which transitions … such as medication reconciliation, assessment of adherence to treatment plans, and identification of adverse … events can facilitate intensified treatment and/or mobilize clinic supports.

319. Statistical Process Control: Possible Uses to Monitor and Evaluate Patient-Centered Medical Home Models (pdf file)
     pcmh.ahrq.gov/sites/default/files/attachments/StatisticalProcess_032513comp.pdf
     March 01, 2013 - Measure rare events. … SPC can also be used to follow occurrence of adverse events that tend to be rare, such as failure to … chart (a g-chart, where g stands for geometric distribution), evaluators can track the days between events … to provide a visual representation of the current status and progress for avoiding rare events (Wall

320. Preventing Pressure Injuries in Hospitals
     pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module1/module1_pu-whychange_slides.pptx
     June 16, 2017 - understanding that even small failures in safety protocols or processes can lead to catastrophic or adverse … events if action is not taken to solve the problem. … Memo on never events, July 7, 2008.