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www.cahps.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/how-to-use.html
July 01, 2023 - Studies
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Events … Patients and Families
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events … team members how to apply the Comprehensive Unit-based Safety Program (CUSP) to prevent obstetrical adverse … events.
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www.cahps.ahrq.gov/cpi/about/otherwebsites/pso.ahrq.gov/index.html
August 01, 2022 - Studies
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Events … the creation of PSOs and the development of Common Formats for uniform reporting of patient safety events … external experts who can assist providers in the collection, analysis, and aggregation of patient safety events … access to Common Formats (uniform definitions and reporting formats for collecting information about adverse … events).
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www.cahps.ahrq.gov/practiceimprovement/index.html
August 01, 2022 - Studies
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Events … Prevention
Tools to assist nursing homes that have electronic medical record systems to prevent adverse … events. … Communication and Optimal Resolution (CANDOR) Toolkit
Process for practitioners to use when unexpected events
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-ptsafety-and-covid-19.pdf
November 01, 2021 - ............................................................................... 2
Descriptions of Events … • Patient safety concerns such as falls,
pressure injuries, and adverse medication
events were reported … Among the blood and blood product concerns (n = 10; 3.3%), there were three incidents involving an
adverse … In two instances, adverse reactions to medications used to treat COVID-19 were identified. … intervention in place
o Secondary patient morbidity
• Surgery or anesthesia
o Characteristics of surgical adverse
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.doc
June 09, 2016 - · “Patient safety” is defined as the avoidance and prevention of patient injuries or adverse events … to ask questions when something does not seem right
(1
(2
(3
(4
(5
SECTION D: Frequency of Events … Hospital management seems interested in patient safety only after an adverse event happens
(1
(2 … Shift changes are problematic for patients in this hospital
(1
(2
(3
(4
(5
SECTION G: Number of Events
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www.cahps.ahrq.gov/news/newsletters/e-newsletter/872.html
July 01, 2023 - process can enrich clinicians’ understanding of patient and family experience and reduce harms following adverse … diagnostic events. … It describes the most effective ways of eliciting fulsome accounts about diagnosis-related events and … emergency departments to provide nonemergency care to residents, potentially placing residents at risk of adverse … events and generating wasteful Medicare spending.
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www.cahps.ahrq.gov/funding/grantee-profiles/grtprofile-walsh.html
October 01, 2023 - Studies
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Events … Walsh is working to prevent medication errors and adverse drug events among children, particularly those … Her team found that 10 percent of children with leukemia or lymphoma experienced adverse drug events
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/James.pdf
January 01, 2004 - the initial IOM goal
for some injury sources (for example, Brigham & Women’s Hospital in Boston
for adverse … drug events [ADEs]; Intermountain Health Care’s LDS Hospital in
Salt Lake City for ADEs and for postoperative … injuries, and
near misses, because of difficulties in recognizing, tracking, and
summarizing these events … trigger
systems), to successful interventions that addressed specific, single injury sources
(e.g., adverse … drug events), to organizational structures (e.g., building a culture of
safety; nursing roles; teamwork
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www.cahps.ahrq.gov/news/newsletters/e-newsletter/856.html
March 01, 2023 - section
News
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Events … Articles featured this week include:
Automated capture of intraoperative adverse events using artificial … Near-miss events detected using the emergency department trigger tool . … Effect of apneic oxygenation with intubation to reduce severe desaturation and adverse tracheal intubation-associated … events in critically ill children.
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www.cahps.ahrq.gov/antibiotic-use/long-term-care/safety/index.html
January 01, 2024 - Studies
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Events … Assessment Form (DOCX, 330 KB)
Implementation Guide (PDF, 402 KB)
Learning From Antibiotic–Associated Adverse … Events Form (DOCX, 227 KB)
Gap Analysis Tool (DOCX, 382 KB)
The Four Moments of Antibiotic Decision
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.pdf
December 22, 2017 - • “Patient safety” is defined as the avoidance and prevention of patient injuries
or adverse events … 1 2 3 4 5
SECTION D: Frequency of Events Reported
In your hospital work area/unit, when the … Hospital management seems interested in patient safety only after an
adverse event happens ....... … 1 2 3 4 5
SECTION G: Number of Events Reported
In the past 12 months, how many event reports
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/resources/hospscanform.pdf
March 22, 2017 - • “Patient safety” is defined as the avoidance and prevention of patient injuries
or adverse events … 1 2 3 4 5
SECTION D: Frequency of Events Reported
In your hospital work area/unit, when the … Hospital management seems interested in patient safety only after an
adverse event happens ....... … 1 2 3 4 5
SECTION G: Number of Events Reported
In the past 12 months, how many event reports
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Implement_Hndbook_508_v2.pdf
April 01, 2011 - ------------------------------------------------------------------- 9
How to prevent adverse events … one study.1 Of these adverse events, three-quarters could
have been prevented or ameliorated. … At this time, no
consensus exists on the single best method to prevent adverse events after
discharge … The incidence and severity of adverse
events affecting patients after discharge from the hospital. … How to prevent adverse events after discharge
How does the IDEAL Discharge Planning strategy improve
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Implement_Hndbook_508_v2.docx
April 01, 2011 - 9
How to prevent adverse events after discharge 11
How does the IDEAL Discharge Planning strategy improve … study.1 Of these adverse events, three-quarters could have been prevented or ameliorated. … How to prevent adverse events after discharge
Many of the challenges described above can be attributed … At this time, no consensus exists on the single best method to prevent adverse events after discharge … The incidence and severity of adverse events affecting patients after discharge from the hospital.
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www.cahps.ahrq.gov/patient-safety/settings/hospital/resource/qitool/webinar080116/index.html
December 01, 2017 - mortality for pediatric surgical procedures
Rates of potentially avoidable complications and adverse … for Selected Procedures)
IQI 91 (Mortality for Selected Conditions)
PSI 90 (Patient Safety and Adverse … Events Composite)
PDI 19 (Pediatric Patient Safety for Selected Indicators) are not in ICD-10 v6.0 … Consider inserting here the deidentified story of a patient who suffered the adverse event captured by … References
Slide 48
Sample Best Practices
Pressure ulcers represent an important patient adverse
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www.cahps.ahrq.gov/news/newsletters/e-newsletter/900.html
February 01, 2024 - Studies
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Events … section
News
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Events … Reducing Adverse Events Related to Anticoagulants .
Implicit Bias Training .
Deprescribing . … Computerized Clinical Decision Support To Prevent Medication Errors and Adverse Drug Events .
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4n_combo_iqi-mortalityreview-bestpractices.pdf
May 20, 2016 - multidisciplinary review is required to identify system processes that may result
in failures in care, adverse … events, and mortality … department within 3 days of discharge
∗ Death associated with drug reaction
∗ Death associated with adverse … department within 3 days of discharge
∗ Death associated with drug reaction
∗ Death associated with adverse … Summary data of sentinel events reviewed by The Joint Commission.
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www.cahps.ahrq.gov/news/newsletters/e-newsletter/875.html
August 01, 2023 - Studies
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Events … section
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Events … Hospitalization due to adverse drug events in older adults with cancer: a retrospective analysis . … Relationship between in-hospital adverse events and hospital performance on 30-day all-cause mortality
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www.cahps.ahrq.gov/talkingquality/translate/compare/choose/standard.html
January 01, 2023 - Studies
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Events … The Standard for “Never Events”
There is one kind of standard that is beginning to emerge in health … care: the standard of “never” or zero percent for certain adverse and preventable events. … These events are preventable and should never happen.”
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-science-safety.pptx
May 01, 2017 - Incidence of adverse drug events and potential adverse drug events. JAMA. 1995;274(1):29–34.