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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.
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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.
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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
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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
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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
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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
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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
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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.
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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
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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
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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.
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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
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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
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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.
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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.
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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.
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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.
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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.
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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.
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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.