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Showing results for "adverse events".
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  1. pcmh.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-1/guide.html
    September 01, 2017 - Patients and Families About AHRQ's Quality & Patient Safety Work Patient Safety News and Events … We understand that even small failures in safety protocols can lead to catastrophic or adverse events
  2. pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy2/Strat2_Implement_Hndbook_508.pdf
    April 30, 2013 - where they can interact with the health care team • This handout gives information on routine events … One study found that more than 70 percent of adverse events are caused by breakdowns in communication … to Improve Quality strategy may also help to meet other goals related to patient safety and never events
  3. pcmh.ahrq.gov/sites/default/files/wysiwyg/teamstepps/instructor/onlinecourse/tsonlinemodule1.pptx
    January 01, 2011 - Washington state, improved the time from decision to the performance of a Caesarean section, with no adverse … Video Discussion Think about the breakdowns you observed in the stories: Can you think of similar events … Of course, you would want to scrub them so that you're only sharing the sequence of events.
  4. pcmh.ahrq.gov/downloads/pub/advances/vol4/Miranda.pdf
    July 01, 2004 - collaborative patient-physician relationship (e.g., “Make sure your doctor knows about any allergies and adverse … Medications and adverse drug events are a key and often-cited patient safety topic that patient behavior
  5. pcmh.ahrq.gov/healthsystemsresearch/hspc-research-study/breadth-and-focus.html
    July 01, 2021 - effective strategies to reduce medical errors and harms, such as healthcare-associated infections, adverse … drug events, and preventable hospital readmissions ( Agency for Healthcare Research and Quality, 2018 … the provision of a treatment as appropriate), as well as both intermediate (e.g., disease control, adverse … patient safety events, patient experience) and definitive outcomes of care (e.g., quality of life, mortality
  6. pcmh.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/lbpinject-topicref.pdf
    March 03, 2014 - years of age and remains common in persons 65 years of age and older.3 Low back pain can have major adverse … health care utilization • For Key Question 4: Harms, including bleeding, infection, neurological events
  7. pcmh.ahrq.gov/hai/cusp/modules/nursing/nursing-notes.html
    December 01, 2012 - Quality/Safety Say: Nurse managers should obtain data on quality outcomes and adverse events monthly
  8. pcmh.ahrq.gov/hai/cauti-tools/archived-webinars/ed-catheter-insertions-transcript.html
    December 01, 2017 - So one event can lead to multiple other events, and I’m now on the slide – that is slide 6, I think – … Adverse drug events can lead to urinary retention, so the use of the catheter.
  9. pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module1/module1_fall-prevention.docx
    March 01, 2013 - We understand that even small failures in safety protocols can lead to catastrophic or adverse events
  10. pcmh.ahrq.gov/teamstepps/instructor/fundamentals/module1/igintro.html
    June 01, 2019 - Prevent adverse drug events. Prevent central line infections.
  11. pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/essentials/coursemgmt-cx062819.pdf
    January 01, 2007 - materials is inspired by the John Kotter (2006) book Our Iceberg is Melting, Changing and Succeeding Under Adverse … curriculum was derived from John Kotter’s book Our Iceberg Is Melting: Changing and Succeeding Under Adverse … teamstepps.ahrq.gov/abouttoolsmaterials.htm%23orderMaterials ☐ Ensure that all instructors know the sequence of events … • Incorporate only vignettes and examples from events that actually happened.
  12. pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/essentials/coursemgmt.pdf
    January 01, 2007 - materials is inspired by the John Kotter (2006) book Our Iceberg is Melting, Changing and Succeeding Under Adverse … curriculum was derived from John Kotter’s book Our Iceberg Is Melting: Changing and Succeeding Under Adverse … teamstepps.ahrq.gov/abouttoolsmaterials.htm%23orderMaterials ☐ Ensure that all instructors know the sequence of events … • Incorporate only vignettes and examples from events that actually happened.
  13. pcmh.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/healthited-issuebrief.pdf
    February 01, 2021 - increased patient knowledge and was associated with high trust in the physician, low CT use, and no adverse … patient events.
  14. pcmh.ahrq.gov/data/infographics/hac-rates-decline.html
    August 01, 2018 - SHARE: More topics in this section Data & Analytics Data Infographics Data Visualizations Data Tools Data Innovations All-Payer Claims Databases Healthcare Cost and Utilization Project (HCUP) Medical Expenditure Panel Survey…
  15. pcmh.ahrq.gov/sites/default/files/wysiwyg/teamstepps/instructor/onlinecourse/tsonlinemodule8.pptx
    March 28, 2006 - Kotter on change management, Leading Change and Our Iceberg is Melting: Changing and Succeeding Under Adverse … They've had some events that have occurred that really are rallying them now.
  16. pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module1/igintro-cx062819.pdf
    January 01, 2007 - evidence-based care for acute myocardial infarction, to prevent deaths from heart attack; – Prevent adverse … drug events; – Prevent central line infections; – Prevent surgical site infections; and
  17. pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module1/igintro.pdf
    January 01, 2007 - evidence-based care for acute myocardial infarction, to prevent deaths from heart attack; – Prevent adverse … drug events; – Prevent central line infections; – Prevent surgical site infections; and
  18. pcmh.ahrq.gov/sites/default/files/attachments/pcpf-module-12-intro-to-assessing-practices.pdf
    September 01, 2015 - reporting systems and their use Safety and reliability  Medication error monitoring and prevention  Adverse
  19. pcmh.ahrq.gov/teamstepps/instructor/reference/learnbench.html
    March 01, 2014 - Meeting as a team to debrief the events. Explaining the protocol deviations.
  20. pcmh.ahrq.gov/sites/default/files/publications2/files/dxsafety-issuebrief-education.pdf
    March 11, 2022 - Inadequacies of physical examination as a cause of medical errors and adverse events: a collection of … Serious misdiagnosis-related harms in malpractice claims: The “Big Three” – vascular events, infections … Internal medicine residents’ exposure to and confidence in managing hospital acute clinical events.

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