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www.qualitymeasures.ahrq.gov/hai/universal-icu-decolonization/universal-icu-ape2.html
September 01, 2013 - Studies
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Events … Safety and Adverse Events
Universal ICU Decolonization
Do:
Use chlorhexidine
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January 01, 2012 - Studies
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Events … ensure safe and seamless transitions of patients from one care setting to another, reducing preventable adverse … events, drug-related errors, and other problems.
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www.qualitymeasures.ahrq.gov/es/topics/index.html?page=1
January 01, 2012 - Studies
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AHRQ Views
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Events … ensure safe and seamless transitions of patients from one care setting to another, reducing preventable adverse … events, drug-related errors, and other problems.
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/perinatal_care_toolkit_fullcolor.pdf
May 01, 2017 - Ways to reduce obstetrical adverse events include improving teamwork and communication
among care teams … Root cause analyses of adverse
events and near-misses (events that did not produce
patient injury) … EARLY IMPACTS
The most recent root cause analyses of adverse events
and near-misses indicated that … poor communication is
no longer a root cause; in fact, near-misses and adverse
events attributed to … The weighted
adverse events included in the measure are in-house maternal death, in-house
neonatal
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/perinatal_care_toolkit_lowvision.pdf
May 01, 2017 - Ways to reduce obstetrical adverse events include improving teamwork and communication
among care teams … Root cause analyses of adverse
events and near-misses (events that did not produce
patient injury) … EARLY IMPACTS
The most recent root cause analyses of adverse events
and near-misses indicated that … poor communication is
no longer a root cause; in fact, near-misses and adverse
events attributed to … The weighted
adverse events included in the measure are in-house maternal death, in-house
neonatal
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www.qualitymeasures.ahrq.gov/news/events/ahrq-research-summit-diagnostic-safety-biosketches.html
September 01, 2016 - for health care safety and quality in a variety of fields, including patient engagement, response to adverse … events, diagnostic error reduction, rapid response, and infection prevention, among others. … Safety Monitoring System, a nationwide surveillance project aimed at identifying the rates of specific adverse … events within the Medicare population. … paper, and led the AHRQ-Brigham medication safety HIT CERT CEDAR (Calling for Earlier Detection of Adverse
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www.qualitymeasures.ahrq.gov/news/newsletters/e-newsletter/878.html
August 01, 2023 - Studies
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Events … section
News
Newsroom
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Events … (Source: JAMA Network Open , Complications, Adverse Drug Events, High Costs, and Disparities in Multisystem … include:
Common contributing factors of diagnostic error: a retrospective analysis of 109 serious adverse
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/officebasedcare/impworkbook.pdf
December 11, 2015 - □ Adverse event due to a breakdown in team skills (e.g., communications, situation monitoring,
mutual … Near-miss(es) due to breakdowns in team skills
□ Staff members are concerned that we could have an adverse … patient satisfaction; improved performance on a
relevant health care quality measure; decreased rates of adverse … events or near-misses)
Who will be involved in the change?
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www.qualitymeasures.ahrq.gov/talkingquality/explain/share-info/highlight.html
September 01, 2019 - Studies
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Events … For example, in the next few years, we may see systems that enable patients to report on adverse events
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www.qualitymeasures.ahrq.gov/news/newsletters/e-newsletter/821.html
June 01, 2022 - Studies
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Events … section
News
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Events … Analysis of Hospital-Level Readmission Rates and Variation in Adverse Events Among Patients With Pneumonia … Assessing adverse event reports of hysteroscopic sterilization device removal using natural language
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www.qualitymeasures.ahrq.gov/news/newsletters/e-newsletter/803.html
March 01, 2022 - Studies
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Events … section
News
Newsroom
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Events … This included reductions in the use of fluoroquinolones, a class of antibiotics known to cause adverse … Relative risks of adverse events among older adults receiving opioids versus NSAIDs after hospital discharge
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www.qualitymeasures.ahrq.gov/sops/bibliography/index.html
January 01, 2024 - Studies
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Events … The association between patient safety culture and adverse events - A scoping review. … The relationship between patient safety culture and patient safety competency with adverse events: A
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www.qualitymeasures.ahrq.gov/hai/universal-icu-decolonization/universal-icu-intro.html
September 01, 2013 - Studies
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Events … Safety and Adverse Events
This enhanced protocol is based on materials successfully used
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www.qualitymeasures.ahrq.gov/es/hai/universal-icu-decolonization/universal-icu-ape3.html
September 01, 2013 - Studies
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Events … Safety and Adverse Events
Universal ICU Decolonization Protocol for CHG Bathing
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September 01, 2013 - Studies
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Events … Safety and Adverse Events
Universal ICU Decolonization Protocol for CHG Bathing
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www.qualitymeasures.ahrq.gov/es/hai/universal-icu-decolonization/universal-icu-intro.html
September 01, 2013 - Studies
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Events … Safety and Adverse Events
This enhanced protocol is based on materials successfully used
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2016-materials/teamstepps-monthly-webinar-april2016.pptx
January 01, 2016 - 05.2 Page ‹#›
TeamSTEPPS®
Clinical Performance & Safety Culture
Slide ‹#›
Upcoming TeamSTEPPS Events … 05.2 Page ‹#›
TeamSTEPPS®
Clinical Performance & Safety Culture
Slide ‹#›
Upcoming TeamSTEPPS Events … Register at: https://tslms.org
Learn more and register for all events at www.TeamSTEPPSportal.org … healthcare
Optimizing patient outcomes by improving communication and other teamwork skills
Reducing adverse … patient events related to communication breakdowns and/or poor teamwork
TEAMSTEPPS 05.2
Mod 1 05.2
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hsops-items-composites.pdf
February 16, 2021 - Hospital management seems interested in patient safety only after an adverse event happens. … Frequency of Events Reported
(Never, Rarely, Sometimes, Most of the time, Always)
D1. … Number of Events Reported
(No event reports, 1 to 2 event reports, 3 to 5 event report, 6 to 10 event
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/resources/infotranshsops.pdf
September 01, 2009 - Hospital management seems interested in patient safety only after an adverse event
happens. … usually show
interest in patient safety—they show interest in patient safety only when there is an adverse … Frequency of Events Reported (More about this item: Refers to reports made to someone
in authority or … Number of Events Reported
(No event reports, 1 to 2 event reports, 3 to 5 event reports, 6 to 10 … Frequency of Events Reported
9. Teamwork Across Units
10. Staffing
11.
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/stpra/stpra.pdf
March 01, 2012 - The
risk for such adverse events increases when surgery is performed in an environment that is less … It utilizes both quantitative and qualitative data to “map” the risks associated with
adverse outcomes … interact with one another and either individually or collectively combine to
contribute to the overall adverse … modeling of complex interactions and dependencies among the multiple risk points
that may lead to the adverse … this approach is determining the probabilities associated with
human breakdowns that contribute to adverse