Results

Total Results: 398 records

Showing results for "adverse events".
Users also searched for: patient safety indicators

341. TeamSTEPPS: Rapid Response Systems (pdf file)
     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 adverse … events. … •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.

342. Strategy 3: Nurse Bedside Shift Report Implementation Handbook (pdf file)
     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 adverse … events 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

343. Enhancing Safety for Patients with Limited English Proficiency Train-the-Trainer Instructor Guide (pdf file)
     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

344. 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?

345. Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department (pdf file)
     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 adverse … events 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

346. Module 1: Preventing Pressure Injuries in Hospitals (doc file)
     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

347. Readiness Assessment Survey (doc file)
     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.

348. Readiness Assessment Survey (doc file)
     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.

349. Is Your Organization Ready for TeamSTEPPS™? (pdf file)
     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

350. Is Your Organization Ready for TeamSTEPPS™? (pdf file)
     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

351. Cognitive Task Analysis: Methods to Improve Patient-Centered Medical Home Models by Understanding and Leveraging its Knowledge Work | PCMH Resource Center
     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

352. TeamSTEPPS® Teamwork Perceptions Questionnaire (T-TPQ) Manual | Agency for Healthcare Research and Quality
     pcmh.ahrq.gov/teamstepps/instructor/reference/teamperceptionsmanual.html
     April 01, 2017 - safety, leadership, interpersonal interactions, attitudes toward stress, and knowledge of how to report adverse … events ( Sexton, et al., 2006 ). … The 50-item T-TPQ was tested and refined during three critical events: cognitive interviews, small group

353. Guide to Patient and Family Engagement in Hospital Quality and Safety | Agency for Healthcare Research and Quality
     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

354. CUSP Toolkit Spread Facilitator Notes | Agency for Healthcare Research and Quality
     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?

355. Reinforcing the Value and Roles of Nurses in Diagnostic Safety - Issue Brief (pdf file)
     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 adverse … events. … 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.

356. Preventing Falls in Hospitals
     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 adverse … events if action is not taken to solve the problem.

357. AHRQ's 35th Anniversary | Agency for Healthcare Research and Quality
     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

358. Readiness Assessment Survey (pdf file)
     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.

359. Readiness Assessment Survey (pdf file)
     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.

360. Selected Best Practices and Suggestions for Improvement (pdf file)
     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