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2721. Introduction and Methods | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/nhqrdr/chartbooks/intro.html
      June 01, 2018 - These measures generally represent rates of adverse events or deaths.

2722. Six Building Blocks How-To-Implement Toolkit: Fast Track Approach Guide (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/ambulatory/6bb-toolkit-fasttrack.pdf
      January 12, 2021 - Any patient using LtOT, regardless of dose, has a risk of adverse events, including overdose; 2.

2723. The PRIDx framework to engage payers in reducing diagnostic errors in healthcare (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/topics/pridx-framework.pdf
      July 05, 2023 - Diagnostic Excellence, Mea- sure Dx: A Resource To Identify, Analyze, and Learn From Diagnostic Safety Events … If incentives are too detailed, prescriptive, or misaligned, they may have adverse effects on clinician

2724. High-Risk Deliveries at Facilities with Level 3 or Higher NICU Services on Campus (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/availability/chipra-0123-fullreport.pdf
      November 01, 2019 - respiratory), obstetric shock, pulmonary embolism, amniotic embolism, eclampsia, septicemia, cardiac events … Additional studies suggest that on the continuum of care to adverse pregnancy outcomes, there are a … Inadequate physician supervision is an important cause of adverse events around delivery.

2725. High-Risk Deliveries at Facilities with 24/7 In-House Physician Coverage Dedicated to the Obstetrical Service by an Anesthesiologist Who Is Qualified to Provide Obstetrical Anesthesia (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/availability/chipra-0121-fullreport.pdf
      October 01, 2019 - respiratory), obstetric shock, pulmonary embolism, amniotic embolism, eclampsia, septicemia, cardiac events … Additional studies suggest that on the continuum of care to adverse pregnancy outcomes, there are a … Inadequate physician supervision is an important cause of adverse events around delivery.

2726. High-Risk Deliveries at Facilities With 24/7 In-House Physician Capable of Safely Managing Labor and Delivery and Performing a Cesarean Section, Including an Emergent Cesarean Section (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/availability/chipra-0120-fullreport.pdf
      May 01, 2018 - respiratory), obstetric shock, pulmonary embolism, amniotic embolism, eclampsia, septicemia, cardiac events … Additional studies suggest that on the continuum of care to adverse pregnancy outcomes, there are a … Inadequate physician supervision is an important cause of adverse events around delivery.

2727. High-Risk Deliveries at Facilities with 24/7 In-House Blood Banking/Transfusion Services - Report (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/availability/chipra-0122-fullreport.pdf
      September 01, 2019 - respiratory), obstetric shock, pulmonary embolism, amniotic embolism, eclampsia, septicemia, cardiac events … Additional studies suggest that on the continuum of care to adverse pregnancy outcomes, there are a … Inadequate physician supervision is an important cause of adverse events around delivery.

2728. Declines in Hospital-Acquired Conditions from 2014 to 2016 | Agency for Healthcare Research and Quality
      www.ahrq.gov/data/infographics/hac-rates-decline.html
      August 01, 2018 - Declines in Hospital-Acquired Conditions from 2014 to 2016 Declines in Hospital-Acquired Conditions from 2014 to 2016 (PDF, 6.9 MB) Source:   AHRQ National Scorecard on Rates of Hospital-Acquired Conditions .

2729. 3. Assessment Plan and Methodology | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/crcscreeningrpt/crcscreen3.html
      April 01, 2018 - achieve its intended (positive) impact without additionally causing (negative) unintended effects or adverse … Prevailing conditions and events occurring in the external environment that could affect the implementation

2730. Final Progress Report: Advancing Quality Measurement and Care Improvement with Health Information Exchange (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/shapiro-report.pdf
      January 01, 2025 - The association between emergency department crowding and adverse cardiovascular outcomes in patients

2731. Behind the Scenes: Patient Safety in the Operating Room and Central Materiel Service During Deployments (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Vane.pdf
      February 01, 2005 - Behind the Scenes: Patient Safety in the Operating Room and Central Materiel Service During Deployments 469 Behind the Scenes: Patient Safety in the Operating Room and Central Materiel Service During Deployments Elizabeth A. P. Vane, Edward Drost, Daryl Elder, Yvonne Heib Abstract The United States Army per…

2732. Strategy 1: Working with Patients & Families as Advisors (Implementation Handbook) (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy1/Strat1_Implement_Hndbook_508_v2.pdf
      January 28, 2011 - to longer-term benefits including:1 • Better health outcomes for patients • Reduced errors and adverse … events • Increased patient loyalty • Reduced risk of malpractice • Increased employee satisfaction … The object is to promote learning from these types of events with the goal of identifying opportunities … When patients and families serve as advisors, there may be events or circumstances that prevent them … Many hospitals use a process called root-cause analysis to illuminate the events and decisions that

2733. Final Progress Report: Simulation Training For Rapid Assessment And Improved Teamwork (STRAIT) (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/16651-Weinger-draft-1.pdf
      February 02, 2010 - Study Rationale Communication failures continue to be the most frequently cited “root cause” of adverse … events reported to The Joint Commission (personal communication, Margaret VanAmringe, February 2, … accurately and consistently portray the clinical role and also respond appropriately to unexpected turns of events

2734. Final Progress Report: A Formal Approach to Detecting and Correcting Simultaneous Masking in the IEC 60601-1-8 International Medical Alarm Standard (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/bolton-report.pdf
      October 22, 2019 - time was explicitly represented by a clock and simulation steps had to account for the number of time events … states, the model computes a set of T discrete times based on the total number of times when change events … probability that medical practitioners will hear the alarms, respond to them appropriately, and thus avoid adverse

2735. Final Progress Report: A Formal Approach to Detecting and Correcting Simultaneous Masking in the IEC 60601-1-8 International Medical Alarm Standard (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/bolton-report.pdf
      January 01, 2024 - time was explicitly represented by a clock and simulation steps had to account for the number of time events … states, the model computes a set of T discrete times based on the total number of times when change events … probability that medical practitioners will hear the alarms, respond to them appropriately, and thus avoid adverse

2736. Final Progress Report: Simulation Training For Rapid Assessment And Improved Teamwork (STRAIT) (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/weinger-report.pdf
      January 01, 2024 - Study Rationale Communication failures continue to be the most frequently cited “root cause” of adverse … events reported to The Joint Commission (personal communication, Margaret VanAmringe, February 2, … accurately and consistently portray the clinical role and also respond appropriately to unexpected turns of events

2737. Appendix D. Site Visit Process Comparison | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/stpra/stpraapd.html
      April 01, 2018 - Intake information collected: antibiotics taken, previous anesthesia experiences, allergies, recent events

2738. Diagnostic Excellence in U.S. Rural Healthcare: A Call to Action (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/resources/issue-briefs/dx-safety-rural-healthcare.pdf
      July 01, 2024 - these errors contribute to approximately 10 percent of patient deaths and 6-17 percent of hospital adverse … events.4 The National Academy of Medicine (NAM) defines diagnostic errors as the failure to establish … Serious misdiagnosis-related harms in malpractice claims: the “Big Three”–vascular events, infections

2739. References (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/ltvv-litreview.docx
      January 01, 2017 - findings, the authors could not conclude that protective mechanical ventilation prevents some of the adverse … There was no evidence that protective mechanical ventilation prevents some of the adverse effects of

2740. 2016 National Healthcare Quality and Disparities Report Introduction and Methods (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/nhqdr16/2016qdrintromethods.pdf
      July 01, 2017 - These measures generally represent rates of adverse events or deaths.