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ce.effectivehealthcare.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-fac-notes.html
December 01, 2017 - Slide 2: Learning Objectives
Say:
At the end of this module, you will be able to–
Describe the … identify what actions will plug those holes, reengineer the system to catch holes before they line up, and end … Slide 24: Case Study: Renal Transplant
Say:
Let’s consider a case study of a renal transplant patient … Thus, a new care team entered the renal transplant patient’s room at 7 a.m. … Slide 28: Case Study: Renal Transplant
Say:
Look at the system.
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/report/rep1.html
June 01, 2010 - Multiple Chronic Conditions
On-Time
Quality of Life
Ambulatory Care
End-Stage … Renal Disease (ESRD) Clinics
Pharmacy
Multiple Settings
Quality Measures
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb8txt.html
December 01, 2017 - Multiple Chronic Conditions
On-Time
Quality of Life
Ambulatory Care
End-Stage … Renal Disease (ESRD) Clinics
Pharmacy
Multiple Settings
Quality Measures
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb2txt.html
December 01, 2017 - Multiple Chronic Conditions
On-Time
Quality of Life
Ambulatory Care
End-Stage … Renal Disease (ESRD) Clinics
Pharmacy
Multiple Settings
Quality Measures
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ce.effectivehealthcare.ahrq.gov/hai/index.html
March 01, 2024 - Reducing Infections in End-Stage Renal Disease (ESRD) Facilities
This field-tested toolkit helps dialysis
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/report/apiiia.html
June 01, 2010 - Multiple Chronic Conditions
On-Time
Quality of Life
Ambulatory Care
End-Stage … Renal Disease (ESRD) Clinics
Pharmacy
Multiple Settings
Quality Measures … Outcome and Assessment Information Set (OASIS) measures or measures of appropriate care for people with end-stage … renal disease. … services and outcomes; additional demographic items and questions about proxy respondents at survey end
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu7a.html
August 01, 2017 - Labor and Delivery Units
Emergency Department
Long Term Care
Ambulatory Care
End-Stage … Renal Disease (ESRD) Clinics
Pharmacy
Multiple Settings
Quality Measures … A Stage 2 pressure injury/ulcer may have slough in its base.
21. … A Stage 4 pressure injury/ulcer never has undermining.
72. … A Stage 4 pressure injury/ulcer never has undermining.
False
72.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects.pptx
December 01, 2017 - solving
Learning From Defects 2
AHRQ Safety Program For Surgery – Implementation
SAY:
At the end … identify what actions will plug those holes, reengineer the system to catch holes before they line up, and end … transplant patient.
24
Case Study: Renal Transplant
Who: A patient bleeding after renal transplant … OR at 0600, necessitating additional lines
In OR: Patient stabilized and surgery begins
Setting the stage … 27
Case Study: Renal Transplant
What happened?
Why did it happen?
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ce.effectivehealthcare.ahrq.gov/sites/default/files/2024-01/wessell2-report.pdf
January 01, 2024 - Summary of Care
documents (core objective # 15) in cCDA format, as prescribed in the Meaningful Use Stage … with an active prescription for any opioid
(excluding patients with documentation of palliative or end-of-life … Warfarin After Starting an Anti-infective Medication
Appropriate Dosing of NOACs in Patients with Renal … Dysfunction
Annual Renal Function Monitoring for NOACs
Diabetes agents
Avoiding Potential Overtreatment … End the Epidemic: Increasing Access
to Naloxone. [cited 2017 Aug 30].
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/fall-knowledge-test.html
January 01, 2013 - Labor and Delivery Units
Emergency Department
Long Term Care
Ambulatory Care
End-Stage … Renal Disease (ESRD) Clinics
Pharmacy
Multiple Settings
Quality Measures
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/sample-care-plan.html
January 01, 2013 - Labor and Delivery Units
Emergency Department
Long Term Care
Ambulatory Care
End-Stage … Renal Disease (ESRD) Clinics
Pharmacy
Multiple Settings
Quality Measures
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/postfall-assessment.html
January 01, 2013 - Labor and Delivery Units
Emergency Department
Long Term Care
Ambulatory Care
End-Stage … Renal Disease (ESRD) Clinics
Pharmacy
Multiple Settings
Quality Measures
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/assessing-procedures.html
January 01, 2013 - Labor and Delivery Units
Emergency Department
Long Term Care
Ambulatory Care
End-Stage … Renal Disease (ESRD) Clinics
Pharmacy
Multiple Settings
Quality Measures
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/orthostatic-vital-sign.html
January 01, 2013 - Labor and Delivery Units
Emergency Department
Long Term Care
Ambulatory Care
End-Stage … Renal Disease (ESRD) Clinics
Pharmacy
Multiple Settings
Quality Measures
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/red/toolkit/redtool4ref.html
March 01, 2013 - Labor and Delivery Units
Emergency Department
Long Term Care
Ambulatory Care
End-Stage … Renal Disease (ESRD) Clinics
Pharmacy
Multiple Settings
Quality Measures
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/resource/guide/tools.html
October 01, 2016 - Labor and Delivery Units
Emergency Department
Long Term Care
Ambulatory Care
End-Stage … Renal Disease (ESRD) Clinics
Pharmacy
Multiple Settings
Quality Measures
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/roadmap.html
January 01, 2013 - Labor and Delivery Units
Emergency Department
Long Term Care
Ambulatory Care
End-Stage … Renal Disease (ESRD) Clinics
Pharmacy
Multiple Settings
Quality Measures
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/acknowledgements.html
August 01, 2022 - Labor and Delivery Units
Emergency Department
Long Term Care
Ambulatory Care
End-Stage … Renal Disease (ESRD) Clinics
Pharmacy
Multiple Settings
Quality Measures
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/scenarios.html
August 01, 2022 - Labor and Delivery Units
Emergency Department
Long Term Care
Ambulatory Care
End-Stage … Renal Disease (ESRD) Clinics
Pharmacy
Multiple Settings
Quality Measures … Toward the end of the procedure, the nurse notices that Mary has turned blue and stops the procedure.
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/vtguide/preface.html
March 01, 2016 - Labor and Delivery Units
Emergency Department
Long Term Care
Ambulatory Care
End-Stage … Renal Disease (ESRD) Clinics
Pharmacy
Multiple Settings
Quality Measures … extended-duration prophylaxis, and prophylaxis in special populations (e.g., obese patients, patients with renal