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81. Module 4: Teamwork and Communication | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module4/mod4-slides.html
    March 01, 2017 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … Events Adverse event: An injury to a resident caused by medical intervention rather than by the … events happen. … Slide 29: Disclosure and Apology for Unexpected Adverse Outcomes Immediate Response to an Adverse … Event Next Steps in Responding to an Adverse Event Care for the resident.

82. What Is Patient Safety Culture? | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/sops/about/patient-safety-culture.html
    March 01, 2022 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … 2 Hospitals with more positive SOPS scores had: Lower rates of in-hospital complications or adverse … events as measured by AHRQ’s patient safety indicators (PSIs). 3 Patients who reported more positive … Exploring relationships between hospital patient safety culture and adverse events. … The relationship between culture of safety and rate of adverse events in long-term care facilities.

83. The Five Principles of Effective Primary Care-Based Care Coordination for Reducing Potentially Preventable Readmissions (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/patient-safety/rev-reportaddendum.pdf
    March 01, 2021 - events. … If left unaddressed, behavioral health and social needs are key risk factors for postdischarge adverse … events. … events increases after hospitalization. … events.

84. AHRQ Quality Indicator Tools for Data Analytics | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/data/qualityindicators/index.html
    November 01, 2020 - hospital level, the QIs are used to support internal quality improvement, monitoring, and assessment of adverse … events related to patient safety. … Patient Safety Indicators (PSIs) help hospitals assess the incidence of adverse events and in-hospital … More specifically, they focus on potential in-hospital complications and adverse events following surgeries … PDIs focus on potentially preventable complications and iatrogenic events for pediatric patients treated

85. New AHRQ SOPS™ Health Information Technology Patient Safety Supplemental Items for Hospitals - Optimizing (Gandhi) (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospital/healthitwebinar/sops-hit-webcast3-gandhi.pdf
    January 01, 2018 - Safety Tejal Gandhi Handwriting 16 Ways IT Can Improve Safety • Prevent errors and adverse … events • Facilitating a more rapid response after an adverse event has occurred • Tracking and providing … feedback about adverse events Bates, Gawande 2003 Main Strategies for Preventing Errors and AEs

86. Patient Safety Culture and Medical Liability—Recommendations for Measurement, Analysis, and Interpretation: A Commentary | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/patient-safety/reports/liability/waever.html
    August 01, 2017 - Studies of claims have shown that the perceived cause, context, outcome, and response to a given adverse … Paid malpractice claims for adverse events in inpatient and outpatient settings. … Exploring relationships between hospital patient safety culture and adverse events. … Health care professionals as second victims after adverse events: a systematic review. … The natural history of recovery for the healthcare provider “second victim” after adverse patient events

87. Strategy 4: IDEA Discharge Planning (Tool 3) (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_3_Physician_HO_508.pdf
    January 01, 2010 - engaging patients and families in discharge planning Nearly 20 percent of patients experience an adverse … three-quarters of these could have been prevented or ameliorated.1 Common post-discharge complications include adverse … drug events, hospital-acquired infections, and procedural complications.1 Many of these complications … The incidence and severity of adverse events affecting patients after discharge from the hospital.

88. Mod5-Disclosure-Checklist (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/mod5-disclosure-checklist.pdf
    April 01, 2016 - ■ Within 60 minutes after the CANDOR event is identified, advise the patient and/or family that an adverse … ■ Identify the adverse event early in the disclosure. … ■ Explain what is known about why the adverse event occurred; do not speculate. … ■ Tell the patient whether the adverse event was preventable, if known. … Apologize ■ Say you are sorry for the adverse event in a sincere manner early in the conversation.

89. INSTRUCTIONS: Return on Investment Estimation (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/f1-returnoninvestment.pdf
    January 01, 2009 - The cost of adverse drug events in hospitalized patients. JAMA 1997;277:307-11. … Costs of adverse events in intensive care units. Crit Care Med 2007;35(11)2637-8. Pappas SH. … The cost of nurse-sensitive adverse events. … Using patient safety indicators to estimate the impact of potential adverse events on outcomes. … The costs and savings associated with prevention of adverse events by critical care nurses.

90. Improving Patient Safety Systems for Patients With Limited English Proficiency | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/health-literacy/professional-training/lepguide/index.html
    September 01, 2020 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … PowerPoint Presentation: Executive Summary A Guide for Hospitals Research suggests that adverse … Common Causes of Adverse Events for LEP and Culturally Diverse Patients     Systems and Strategies To … Safety     Why Hospitals Should Focus on Patient Safety for LEP Populations     Common Causes of Adverse … Research suggests that adverse events affect LEP patients more frequently, are often caused by communication

91. Improving Patient Safety Systems for Patients With Limited English Proficiency: A Guide for Hospitals (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/publications/files/lepguide.pdf
    September 01, 2012 - Evidence shows that unaddressed language barriers put patients at high risk for adverse events. … The one hospital that stratified their adverse event data by language found clusters of adverse events … Language pro�ciency and adverse events in U.S. hospitals: a pilot study. … Language proficiency and adverse events in U.S. hospitals: a pilot study. … • Emphasize potential differences between patient safety events and adverse events and distinguish

92. AHRQ National Scorecard on Hospital-Acquired Conditions | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/hai/pfp/index.html
    July 01, 2020 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … Condition Rate ( PDF , 237 KB) To improve how the Nation tracks its progress on reducing HACs and other adverse … events, AHRQ is developing the AHRQ Quality and Safety Review System . … This patient safety surveillance system will capture information about HACs and other adverse events

93. Develop a Culture of Safety Around Antibiotic Prescribing | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/antibiotic-use/acute-care/safety/index.html
    June 01, 2021 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … Use Commitment Poster (DOCX) Antibiotic Time Out Tool (DOCX) Identifying Antibiotic–Associated Adverse … Events Form (DOCX) Learning From Antibiotic–Associated Adverse Events Form (DOCX)

94. Strategy 4: IDEA Discharge Planning (Tool 3) (doc file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_3_Physician_HO_508.docx
    January 01, 2010 - for engaging patients and families in discharge planning Nearly 20 percent of patients experience an adverse … three-quarters of these could have been prevented or ameliorated.1 Common post-discharge complications include adverse … drug events, hospital-acquired infections, and procedural complications.1 Many of these complications … The incidence and severity of adverse events affecting patients after discharge from the hospital.

95. Chapter 2: Five Key Recommendations To Improve Patient Safety for LEP Patients | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/health-literacy/professional-training/lepguide/chapter2.html
    September 01, 2020 - events that occur commonly among LEP patients. … A field for whether a hospital interpreter was present at the time of the adverse event or was used at … events among LEP and culturally diverse patients. … events, and analyze their root causes. … events among LEP patients.

96. AHRQ Signals Intent To Fund Clinics To Improve Care for People With Long COVID | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/news/newsletters/e-newsletter/852.html
    February 01, 2023 - section News Newsroom Blog Newsletter AHRQ News Now Events … events on health systems.  … events like multi-organ failure and heart problems, according to two AHRQ-funded studies published in … Food and Drug Administration’s Adverse Event Reporting System from January 2004 through June 2020. … It found a total of 787 reports that pointed to an adverse event from a colchicine drug interaction.

97. Resident COVID-19 Vaccine Administration Record (doc file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/resident-covid-vaccine-administration-record.docx
    May 01, 2022 - Contraindication:__________________________________________________________________________ Adverse … ______________________________ Refer to the CDC’s website for information on contraindications and adverse … events. 5. 4. 6.

98. Staff COVID-19 Vaccine Administration Record (doc file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/staff-covid-vaccine-administration-record.docx
    May 01, 2022 - Contraindication: __________________________________________________________________________ Adverse … _____________________________ Refer to the CDC’s website for information on contraindications and adverse … events. 5. 6.

99. Transforming Care for People Living with Multiple Chronic Conditions (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/mcc-summit/mcc-summit-arlene.pdf
    November 17, 2020 - risk” will go on to develop MCC • Targeted interventions to improve health and reduce the risk of adverse … events and complications among those with multiple chronic conditions (e.g., diabetes, depression, … interventions for those who have complex management issues and who are at “high risk” for avoidable adverse … events, and require a focus on preventing decline, maximizing functioning, and improving quality of

100. PowerPoint Presentation
     www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-slides.pptx
     June 01, 2021 - Learning From Antibiotic-Associated Adverse Events Form Changing the System 12 What Happened? … Use the Learning From Antibiotic-Associated Adverse Events form to develop a plan.   … Completion Guide for the Four Moments of Antibiotic Decision Making Form Learning From Antibiotic-Associated Adverse … Events Changing the System 19 Disclaimer The findings and recommendations in this presentation