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2261. Postdisphone (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/red/toolkit/postdisphone.docx
      January 31, 2013 - Medicines High Alert Medicines Use the guide below to help monitor medicines with significant risk for adverse … events.

2262. Module 1: Preventing Falls in Hospitals—Slide Presentation | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-1/slides.html
      September 01, 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.

2263. Presentation: Program Overview
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/nursedr-early-mobility-protocols-slides.pptx
      January 01, 2017 - mobility Outcomes evaluation Ventilator LOS ICU LOS Hospital LOS Incidence and duration of delirium Adverse … events Nurse-Driven Early Mobility ‹#› AHRQ Safety Program for Mechanically Ventilated Patients

2264. Appendix A: References and Available Abstracts | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/shuttered/acfselection/appendixa.html
      July 01, 2018 - The capability to cope with a MCI serves as a basis for preparedness for non-conventional events. … Events of the past few years including the bombing of the World Trade Center in 1993, the Murrah Federal … This framework will cover the types of events that can cause a surge of patients, the general ways in … which health care facilities respond to these events, and the categories of people who would make up … Fundamental precepts in hospital-based planning for bioterrorist events include having a comprehensive

2265. Enhancing Safety for Patients with Limited English Proficiency Train-the-Trainer Instructor Guide
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/traintrainers/lepigtrainer.pptx
      July 01, 2012 - Proficiency Slide LEP 7 High-Risk Settings and Scenarios SAY: Research shows that 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

2266. Train-the-Trainer Instructor Guide | Agency for Healthcare Research and Quality
      www.ahrq.gov/teamstepps/lep/traintrainers/lepigtrainer.html
      October 01, 2020 - 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. … identified as a primary contributor to the clinical errors found in malpractice cases and sentinel events

2267. Appendix 3: Data Abstraction (xls file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/ced-appendix3-data-abstraction.xlsx
      June 24, 2022 - utilization; NEST_data • The specific data elements required to assess performance and outcomes (including adverse … events and their timing) in the course of the disease or treatment; NEST_data • The appropriate settings … expectations or preferences will providers and patients be expected to have regarding benefits and adverse … NAM2019 Likelihood that beneficial or adverse effects would be reported or observed? … expectations or preferences will providers and patients be expected to have regarding benefits and adverse

2268. TeamSTEPPS Rapid Response Systems Module | Agency for Healthcare Research and Quality
      www.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.

2269. Scisafetynotes (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/understand/scisafetynotes.docx
      September 04, 2012 - . · On average, every patient admitted to an intensive care unit suffers an adverse event. · 44,000 to

2270. Organizational Climate, Stress, and Error in Primary Care: The MEMO Study (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Linzer.pdf
      January 01, 2002 - , our finding from the focus groups that hectic office environments may potentially contribute to adverse … We encourage the internal reporting of all adverse patient care events. 2.5 (0.9) z. … The chaotic office environment plays a prominent role in explaining adverse physician reactions such … remediable contributors to a chaotic environment, the relationship between the chaotic environment and adverse

2271. ICU Assessment Response Guide (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/icu-assessment-guide.pdf
      April 01, 2022 - Rationale: Understanding factors or events that lead the team to focus on CLABSI and/or CAUTI may be … staff, and infection prevention/quality partners are generally recommended after CLABSI and CAUTI events … which members of the group observe work and ask questions to frontline workers about near misses, adverse … events, and system issues contributing to these events.

2272. AHRQ Timeline | Agency for Healthcare Research and Quality
      www.ahrq.gov/cpi/about/timeline/index.html
      March 01, 2025 - 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 … interactions, and to include patients at staff handoffs, allowing the team to stay on top of developing events

2273. Final Progress Report: Minimizing Error, Maximizing Outcome (MEMO): The Physician Worklife Study II (pdf file)
      www.ahrq.gov/sites/default/files/2024-09/linzer-schwartz-report.pdf
      January 01, 2024 - on our focus group findings regarding the potential contribution of a hectic office environment to adverse … published guidelines for care of our three targeted diseases, lack of changes in care after signal events … One finding, the potential contribution of a hectic office environment to adverse patient outcomes, … We encourage the internal reporting of all adverse patient care events. 2.5 (0.9) z. … The chaotic office environment plays a prominent role in explaining adverse physician reactions including

2274. OBC PPT Q4
      www.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2018-materials/ts-obc-webinar-uw.pptx
      January 01, 2018 - patients experience a diagnostic error Paid medical liability claims (Bishop et al, 2013) Half arose from events … Paid malpractice claims for adverse events in inpatient and outpatient settings.

2275. The Impact of Personal Digital Assistant Devices on Medication Safety in Primary Care (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Galt.pdf
      January 01, 2005 - Systems analysis of adverse drug events. ADE Prevention Study Group. … Incidence of adverse drug events and potential adverse drug events. Implications for prevention.

2276. Safety Climate on Hospital Units: A New Measure (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Blegen.pdf
      January 01, 2004 - our study of the impact of working conditions of nurses on medication administration accuracy and adverse … The Safety Climate Scale focuses on organizational commitment to safety, knowledge of how to report adverse … events, and beliefs about systems problems as a cause of error.

2277. Slide 1
      www.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2017-materials/teamstepps-webinar-091317.pptx
      January 01, 2017 - Leaders Team Perceptions Annual Culture of Safety HCAHPS - Satisfaction Core Measures Incident Reports Adverse … Events Switch Model Identify Coaches and Leaders Fundamentals of TeamSTEPPS Simulation Involve Pt.

2278. ACTION III 2019 Project Summaries (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/factsheets/translating/action3/ACTION%20-III-2019-Project-Summaries.pdf
      January 01, 2019 - Each year, approximately 965,000 individuals will have a coronary event, and more than 30 percent of events … It is associated with a wide range of adverse consequences related to physical and mental health (e.g … The risks of adverse medication events also differ for older adults, including falls, respiratory depression … events and opioid use, misuse, and OUD in older adults in primary care; o Their experiences caring … drug events: a systematic review.

2279. AHRQ Safety Program for MRSA Prevention
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/098-cusp-why-choose-cusp-approach.pptx
      October 01, 2024 - Exploring relationships between hospital patient safety culture and adverse events.

2280. Suicide Risk Response: Enhancing Patient Safety Through Development of Effective Institutional Policies (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Bonner.pdf
      January 01, 2004 - to a clinician who can assess the level of urgency of the situation is part of a complex chain of events … Only one reportable adverse event ensued.11 No revisions of the policy were necessary. … Risks to patient privacy in adverse event reporting for HSR&D studies.