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2621. Final Progress Report: The Institute for the Design of Environments Aligned for Patient Safety (IDEA4PS) (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/mcalearney-report.pdf
      September 29, 2020 - what engineers call the signal- to-noise ratio, thereby allowing clinicians to focus on meaningful events … Project 1 improved the signal-to-noise ratio, thereby allowing clinicians to focus on meaningful events … noise through which clinicians must identify particular signals that indicate clinically significant events … what engineers call the signal-to-noise ratio, thereby allowing clinicians to focus on meaningful events … data in a hospital-wide interactive surveillance map may allow for earlier recognition of potential adverse

2622. Final Progress Report: The Institute for the Design of Environments Aligned for Patient Safety (IDEA4PS) (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/mcalearney-report.pdf
      January 01, 2024 - what engineers call the signal- to-noise ratio, thereby allowing clinicians to focus on meaningful events … Project 1 improved the signal-to-noise ratio, thereby allowing clinicians to focus on meaningful events … noise through which clinicians must identify particular signals that indicate clinically significant events … what engineers call the signal-to-noise ratio, thereby allowing clinicians to focus on meaningful events … data in a hospital-wide interactive surveillance map may allow for earlier recognition of potential adverse

2623. Course Management Guide (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/ts2-0ltc_course_mgmt_guide.pdf
      January 01, 2007 - 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 … ☐ Ensure that all instructors know the sequence of events for the course, including plans for breaks …  Incorporate only vignettes and examples from events that actually happened.

2624. Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/studies/index.html?page=62
      January 01, 2024 - The researchers also reported that storytelling using examples of real events was useful. … Utilization Project (HCUP), Patient Safety, Quality Indicators (QIs), Quality Measures, Quality of Care, Adverse … Events, Medicare Andino JJ , Zhu Z , Surapaneni M Interstate telehealth use by Medicare

2625. Nutritional Research Series, Volume 2 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/evidence-based-reports/nutrtp2.pdf
      March 01, 2009 - UL, defined as the highest average daily nutrient intake level that is likely to pose no risk of adverse … Adverse events would also be considered as clinical outcomes. … Very small studies (e.g., case series) may provide useful lists of potential adverse events but are

2626. Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/studies/index.html?page=453
      January 01, 2024 - drug comparisons with regard to key population subgroups, efficacy and effectiveness outcomes, and adverse

2627. Improving Patient Safety in Long-Term Care Facilities: Training Modules (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/ltcinstructor.pdf
      June 01, 2012 - three main components are to: › Gain knowledge and skills to understand systems of care and minimize adverse … Check with a co-worker about any previous history of similar events. d. All of the above. … When procedures for team communication are in place, the number of “adverse events” (negative effects … main components are to : › Gain knowledge and skills to understand systems of care and minimize adverse … objectives, which are to: › Gain knowledge and skills to understand systems of care and minimize adverse

2628. From Public Testimony to Vehicle for Statewide Action: Experience of the Michigan State Commission on Patient Safety (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Valade_46.pdf
      May 05, 2008 - What events should be reported? By whom? To whom? For what purposes? … patients and families access to information through normal channels when medical errors or unexpected events … patients/families and health professionals about health issues, treatments, patient safety concerns, and adverse … events

2629. Learn About CUSP, Facilitator Notes | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/modules/learn/fac-cusp.html
      December 01, 2012 - It provides a comprehensive process to investigate harmful events or patient safety concerns and determine

2630. A Toolkit for Redesign of Health Care (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/toolkit.pdf
      September 01, 2005 - The duration of this planning process underscores the need for a well thought-out sequence of events … Where there any negative events during your hospital stay? … The duration of these events will also be documented. … Reporting of adverse events. New England Journal of Medicine. 2002;347(20):1633- 1638. … Measuring errors and adverse events in health care.

2631. Measure Sets for Additional Perspectives | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/pcpaccountability/pcpacc2.html
      July 01, 2018 - attributable risk of coronary heart disease, hemoglobin A1c values, cholesterol levels and cardiac events … of cholesterol levels and hemoglobin A1c scores among diabetics and cholesterol levels and cardiac events

2632. The Mobile Mock Operating Room: Bringing Team Training to the Point of Care (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Paige_6.pdf
      January 24, 2008 - In this high-risk setting, lapses in teamwork can potentially lead to adverse patient outcomes. … Each scenario 6 involved one of the following intraoperative critical events to act as a catalyst … debriefing discussions, the facilitator used video playback as needed to facilitate reflection on critical events … to real life OR settings facilitates implementation and minimizes cancellations due to unexpected events

2633. Attachments 5.1 through 5.5 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-145-materials-v-a.pdf
      June 25, 2014 - care clinician should titrate doses of medication for ADHD to achieve maximum benefit with minimum adverse … therapy requires a higher level of family involvement, whereas methylphenidate has some potential adverse … might experience increased mood lability and dysphoria.57 For the nonstimulant atomoxetine, the adverse … nonstimulant a2­ adrenergic agonists extended-release guanfacine and extended-release clo­ nidine, adverse … events described in adults.14 IOM Domains of  Effective Health Care  Timely Quality  Equitable

2634. The University of Wisconsin-Madison Multidisciplinary Graduate Certificate in Patient Safety (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Karsh.pdf
      April 08, 2004 - suggest that CME courses on patient safety teach system structures of health care and that they focus on adverse … drug events, errors of omission and commission, discharge planning, transitions in levels of care,

2635. Final Progress Report: NPSF Joint Medical-Legal Conference at SMU (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/nance-report.pdf
      January 01, 2025 - patient who has been apologized to and fully informed about the details of a medical error that had adverse … has to be the faith of the practitioners/reporters that there will be no retribution or personally adverse

2636. Ed-Catheter-Insertions-Transcript (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/ed-catheter-insertions-transcript.doc
      September 10, 2013 - 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.

2637. SOPS™ Value and Efficiency Supplemental Items for Hospitals and Medical Offices Webcast Transcript (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/valuewebcasttranscript.pdf
      January 09, 2018 - the Hospital SOPS survey, you would add the Value and Efficiency items between Section G, Number of Events … We've done it for a number of issues, including adverse drug reactions, restraint reduction, and it's … receiving email updates about the patient safety culture surveys, including announcements of future events … It helps to improve our offerings and plan future events that meet your needs.

2638. Emergency Department and Catheter Insertion | Agency for Healthcare Research and Quality
      www.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.

2639. Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/studies/index.html?page=218
      January 01, 2024 - Keywords: Healthcare Cost and Utilization Project (HCUP), Hospital Readmissions, Surgery, Risk, Adverse … Events, Outcomes Rosenman ED , Vrablik MC , Brolliar SM Targeted simulation-based leadership

2640. Development of a Web-Based Patient Safety Resource: AHRQ Patient Safety Network (PSNet) (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Sehgal_64.pdf
      April 02, 2008 - Background/Assessment/Recommendation) Nurse staffing ratios “Falls” Medication errors/preventable adverse … drug events “Medication reconciliation” Culture of safety “Communication” Look-alike, sound-alike