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Showing results for "adverse events".
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241. Declines in Hospital-Acquired Conditions from 2014 to 2016 | Agency for Healthcare Research and Quality
     preventiveservices.ahrq.gov/data/infographics/hac-rates-decline.html
     August 01, 2018 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events

242. Uses of Quality Measurement | Agency for Healthcare Research and Quality
     preventiveservices.ahrq.gov/patient-safety/quality-resources/tools/chtoolbx/uses/index.html
     June 01, 2020 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … Patients and Families About AHRQ's Quality & Patient Safety Work Patient Safety News and Events … Providers or plans welcome the opportunity for a practice year without adverse consequences.

243. Strategy 2: Communicating for Improve Quality (Tool 6) (pdf file)
     preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy2/Strat2_Tool_6_Pres_TX_508.pdf
     May 24, 2013 - Research shows patient-centered communication can improve: – Patient safety • More than 70 percent of adverse … events caused by breakdowns in communication – Patient outcomes, including emotional health, functioning

244. Preventing Pressure Injuries in Hospitals
     preventiveservices.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.

245. Train-the-Trainer Instructor Guide | Agency for Healthcare Research and Quality
     preventiveservices.ahrq.gov/teamstepps/lep/traintrainers/lepigtrainer.html
     October 01, 2020 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … Slide Time: 5 minutes 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.

246. Strategy 2: Communicating for Improve Quality (Tool 6)
     preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy2/Strat2_Tool_6_Pres_TX_508.pptx
     July 23, 2010 - families Research shows patient-centered communication can improve: Patient safety More than 70 percent of adverse … events caused by breakdowns in communication Patient outcomes, including emotional health, functioning … For example, one study found that more than 70 percent of adverse events are caused by breakdowns in

247. Surveys on Patient Safety Culture (SOPS) Hospital Survey 2.0: 2021 User Database Report Part I (pdf file)
     preventiveservices.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/2021-HSOPS2-Database-Report-Part-I-508-rev0921.pdf
     January 01, 2021 - Example of Computing Number of Events Reported and Patient Safety Rating . 36 Table N3. … safety events they reported in the past 12 months. … Table 6-3 presents statistics for the number of patient safety events reported. … Reporting Patient Safety Events 74% 7.69% 50% 65% 69% 74% 79% 85% 93% 5. … Disagree/Strongly Disagree Hospital management seems interested in patient safety only after an adverse

248. Network of Patient Safety Databases Falls Chartbook, 2023 (pdf file)
     preventiveservices.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-falls-chartbook-2023.pdf
     January 01, 2023 - extent of harm to the patient after discovery of the incident and after any attempts to minimize adverse … The figures below are based on these 484 and 2,166 events respectively. … The figures below are based on these 1,723 and 4,960 events respectively. … The figures below are based on these 2,443 and 6,229 events respectively. … The figures below are based on these 2,299 and 5,622 events respectively.

249. Health Literacy and Patient and Family Engagement: Strategic Tools to Prevent CAUTI | Agency for Healthcare Research and Quality
     preventiveservices.ahrq.gov/hai/cauti-tools/archived-webinars/health-literacy-slides.html
     December 01, 2017 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … Percent know correct action for hypoglycemic symptoms 38 53.9 72.6 Slide 8 All Sentinel Events … limited health literacy: Poor compliance with medical management Increased risk of: Poor outcomes/adverse … events Infections/prolonged hospital stays Patient/family anxiety Slide 33 Summary: Health

250. Final Progress Report: Implementation of a Medication Reconciliation Toolkit to Improve Patient Safety (MARQUIS2) (pdf file)
     preventiveservices.ahrq.gov/sites/default/files/2024-02/schnipper2-report.pdf
     January 01, 2024 - case to hospital leadership of the return on investment of hiring these personnel (i.e., in reducing adverse … drug events and inpatient length of stay). … Medication Reconciliation to Prevent Adverse Drug Events. … Secondary Medication Reconciliation to Prevent Adverse Drug Events 2018. http://www.ihi.org/Topics/ADEsMedicationReconciliation

251. Hospital Survey on Patient Safety Culture: User's Guide (pdf file)
     preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/userguide/hospitalusersguide.pdf
     July 01, 2018 - provide an overall grade on patient safety for their work area/unit and to indicate the number of events …  “Patient safety” is defined as the avoidance and prevention of patient injuries or adverse events … Hospital management seems interested in patient safety only after an adverse event happens ......... … Hospital management seems interested in patient safety only after an adverse event happens. … Frequency of Events Reported (Never, Rarely, Sometimes, Most of the time, Always) D1.

252. Current State of Diagnostic Safety: Implications for Research, Practice, and Policy - Issue Brief (pdf file)
     preventiveservices.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-current-state.pdf
     January 01, 2024 - ■ Measure Dx: A Resource To Detect, Analyze, and Learn From Diagnostic Safety Events (AHRQ). … Patient record review of the incidence, consequences, and causes of diagnostic adverse events. … Association between cancer-specific adverse event triggers and mortality: a validation study. … An electronic trigger based on care escalation to identify preventable adverse events in hospitalised … Reducing preventable adverse events in obstetrics by improving interprofessional communication skills

253. Strategy 3: Nurse Bedside Shift Report Implementation Handbook (doc file)
     preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy3/Strat3_Implement_Hndbook_508.docx
     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 … are 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

254. Defining Diagnostic Error: A Scoping Review to Assess the Impact of the National Academies’ Report Improving Diagnosis in Health Care (pdf file)
     preventiveservices.ahrq.gov/sites/default/files/wysiwyg/topics/defining-diagnostic-error-a-scoping-review.pdf
     April 27, 2022 - The remaining 2 studies (Giardina et al29,30) analyzed existing data sets of patient reports of adverse … events and patient complaints, respectively. … Secondary analysis of patient reports of adverse Timeliness, accuracy, communication events ( … The determination of error depends on the temporal or sequential context of events. … Tracking Progress in improving diagnosis: a framework for defining undesirable diagnostic events.

255. TeamSTEPPS Rapid Response Systems Module | Agency for Healthcare Research and Quality
     preventiveservices.ahrq.gov/teamstepps/rrs/instructor_slides/rrsinstructmod.html
     October 01, 2014 - 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 data … During a team huddle, response team members could: Discuss critical issues and emerging events. … and prescribe a course of action for future events.

256. Strategy 3: Nurse Bedside Shift Report Implementation Handbook (pdf file)
     preventiveservices.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

257. SITUATION MONITORING (ppt file)
     preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/rrs/rrsinstructmod.ppt
     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 data … During a team huddle, response team members could: Discuss critical issues and emerging events. … and prescribe a course of action for future events.

258. AHRQ's 35th Anniversary | Agency for Healthcare Research and Quality
     preventiveservices.ahrq.gov/cpi/about/35th-anniversary/index.html
     April 01, 2024 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … 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

259. AHRQ Safety Program for Surgery: Final Report (pdf file)
     preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/safe_surgery_finalreport.pdf
     December 01, 2017 - Recent data from the Medicare Patient Safety Monitoring System found that rates of adverse events did … central line-associated bloodstream infection, ventilator-associated pneumonia) and post-procedural adverse … events (e.g., postoperative venous thromboembolic events) significantly increased. … a program to improve local safety culture did not lead to significant reductions in SSI and other adverse … events were handled; and • Where improvements were needed.

260. The TeamSTEPPS for Improving Diagnosis Team Assessment Tool: Scale Development and Psychometric Evaluation (pdf file)
     preventiveservices.ahrq.gov/sites/default/files/wysiwyg/topics/dx-team-assessment-scale-jtcommjqualpatsaf.pdf
     February 01, 2024 - work as an effective team. 4 According to The Joint Commis- sion, one of the most reviewed sentinel events … Team members use daily/weekly huddles and briefs to stay informed, address issues, share unexpected events … communication practices to identify opportunities for improvement (for example, this survey tool, debriefing events … Team members have a systematic process in place to capture and learn from near misses and no-harm adverse … events that occur because of communication gaps