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Showing results for "adverse events".
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  1. pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/rrs/instructor_slides/rrsinstructmod.pdf
    January 01, 2008 - should be prioritized based on the risk to patients and on the prevalence and severity of targeted adverseevents. … •Quality Improvement – Supports Activators and Responders by reviewing RRS events and evaluating … During a team huddle, response team members could: •Discuss critical issues and emerging events. … and prescribe a course of action for future events.
  2. pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy3/Strat3_Implement_Hndbook_508.pdf
    August 01, 2010 - Nurse shift changes require the successful transfer of information between nurses to prevent adverseevents and medical errors. … One study found that more than 70 percent of adverse events are caused by breakdowns in communication … on the Centers for Medicare and Medicaid Services’ list of hospital-acquired complications “never events … communication during nurse transitions, for example: • Reduce the incidence of never events by 5 percent
  3. pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/traintrainers/lepigtrainer.pdf
    July 01, 2012 - LEP The Story of Willie Ramirez SAY: To illustrate why LEP patients are at risk of patient safety events … Language proficiency and adverse events in U.S. hospitals: a pilot study. … is inspired by the 2006 book by John Kotter, Our Iceberg Is Melting: Changing and Succeeding Under Adverse … Our iceberg is melting: changing and succeeding under adverse conditions. … identified as a primary contributor to the clinical errors found in malpractice cases and sentinel events
  4. Spreadnotes (doc file)

    pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/spread/spreadnotes.docx
    August 28, 2012 - ASK: · How did the pilot CUSP team make a case for their project targeting adverse drug events?
  5. pcmh.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/distributed-cognition-er-nurses.pdf
    August 01, 2022 - physician to observe overt and many times more subtle clues, such as changes in vital signs, sensorium, or events … physician by presenting a case and receiving feedback.42 The study reported a significant reduction in adverseevents and near- misses,42 suggesting that distributed cognition played a role by having the physician … Effect of systematic physician cross-checking on reducing adverse events in the emergency department
  6. pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module1/module1_pu-whychange.docx
    July 12, 2017 - We understand that even small failures in safety protocols can lead to catastrophic or adverse events
  7. pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/handouts/trainershandouts_all.docx
    September 01, 2012 - Patient safety events that affect limited-English-proficient (LEP) patients tend to be more severe and … receive professional interpretation services.3 Hospitals have been held liable for LEP patient safety events … Language proficiency and adverse events in U.S. hospitals: a pilot study.
  8. pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/handouts/stafftrainhandouts_all.docx
    September 01, 2012 - Patient safety events that affect limited-English-proficient (LEP) patients tend to be more severe and … receive professional interpretation services.3 Hospitals have been held liable for LEP patient safety events … Language proficiency and adverse events in U.S. hospitals: a pilot study.
  9. pcmh.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/curriculum/teamstepps-3-readiness-form.pdf
    August 01, 2005 - Objective information can originate from a variety of sources, including adverse event and near-miss
  10. pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/readiness/tsreadiness.pdf
    August 01, 2005 - Objective information can originate from a variety of sources, including adverse event and near-miss
  11. pcmh.ahrq.gov/page/cognitive-task-analysis-methods-improve-patient-centered-medical-home-models-understanding-and
    March 01, 2013 - macrocognitive processes include how individuals, teams, and organizations make decisions, make sense of events … CTA methods do exist should the reader wish to investigate the macrocognition of uncommon, critical events … information more comprehensive, organized, and readable, and including decision aids and warnings of adverse … of, what they pay attention to, what options and possibilities they consider, how they make sense of events
  12. pcmh.ahrq.gov/teamstepps/instructor/reference/teamperceptionsmanual.html
    April 01, 2017 - safety, leadership, interpersonal interactions, attitudes toward stress, and knowledge of how to report adverseevents ( Sexton, et al., 2006 ). … The 50-item T-TPQ was tested and refined during three critical events: cognitive interviews, small group
  13. pcmh.ahrq.gov/patient-safety/patients-families/engagingfamilies/index.html
    March 01, 2023 - Primary Care Settings About AHRQ's Quality & Patient Safety Work Patient Safety News and Events
  14. pcmh.ahrq.gov/hai/cusp/modules/spread/notes.html
    December 01, 2012 - Ask: How did the pilot CUSP team make a case for their project targeting adverse drug events?
  15. pcmh.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/nurse-role-dxsafety.pdf
    September 02, 2022 - Discuss the associated tasks and thought processes taking place during those events. 4 Domain 3: … SBAR),27-30 to structure communication with physicians and other diagnostic team members and reduce adverseevents. … in their day-to-day operations. 7 e Any safety events or “good catches” identified from these … Measure Dx: A Resource To Identify, Analyze, and Learn From Diagnostic Safety Events. July 2022.
  16. pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module1/module1_slides_fallprev.pptx
    June 16, 2017 - understanding that even small failures in safety protocols or processes can lead to catastrophic or adverseevents if action is not taken to solve the problem.
  17. pcmh.ahrq.gov/cpi/about/35th-anniversary/index.html
    April 01, 2024 - Hospital-Acquired Conditions show that national efforts to reduce hospital-acquired conditions, such as adverse … drug events and injuries from falls, helped prevent an estimated 8,000 deaths and save $2.9 billion
  18. pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/handouts/stafftrainhandouts_all.pdf
    September 01, 2012 - Patient safety events that affect limited-English-proficient (LEP) patients tend to be more severe … professional interpretation services. 3 Hospitals have been held liable for LEP patient safety events … Language proficiency and adverse events in U.S. hospitals: a pilot study.
  19. pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/handouts/trainershandouts_all.pdf
    September 01, 2012 - Patient safety events that affect limited-English-proficient (LEP) patients tend to be more severe and … professional interpretation services. 3 Hospitals have been held liable for LEP patient safety events … Language proficiency and adverse events in U.S. hospitals: a pilot study.
  20. pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4a_combo_psi03-pressureulcer-bestpractices.pdf
    January 01, 2012 - • Pressure ulcers represent an important patient adverse event that is associated with significant

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