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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/topics/dagnostic-safety-workgroupmeeting-notes-july2022.pdf
November 03, 2022 - • Common Format for Event Reporting – Diagnostic Safety
o AHRQ released the Common Formats for Event … The Event
Description, Users’ Guide and Glossary, and Form are all
available here. … IHS • Enhanced Adverse Event Reporting Capabilities
o IHS Safety Tracking and Response (I-STAR) is deployed … improvement project to better identify and facilitate the
reporting of diagnostic errors through voluntary event
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ce.effectivehealthcare.ahrq.gov/takeheart/training/index.html
February 01, 2023 - Select to view a recording of the webinar, the slides, and an event summary . … Select to view a recording of the webinar, the slides, and an event summary . … Select to access a recording of the webinar, slides, and the event summary of the materials . … Select to access a recording of the webinar, slides, and the event summary of the materials . … Select to access a recording of the webinar, slides, and the event summary of the materials .
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ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-3.html
June 01, 2023 - The Challenge: Most studies eliciting patient experience with medical errors focus on the adverse event … The focus of questions is on the immediate antecedents and outcomes of the adverse event. … is that the ways patients and clinicians interact in the aftermath of that event go unreported. … Exacerbated harms associated with the adverse event. … But only 14 percent more reported such an event from 2 to 5 years before the survey (less than half of
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ce.effectivehealthcare.ahrq.gov/patient-safety/reports/hotline/intro1.html
May 01, 2016 - Importantly, none of these events were documented in the hospital’s adverse event reporting systems. … Similarly, Weingart and colleagues, studying adverse event reports from ambulatory oncology patients, … reporting systems, measures must be taken to ensure that event reporting is acceptable to patients. … At Dana-Farber Cancer Institute, for example, a proposal to collect patient event reports was initially … Appendix C is the Operations Manual, which contains the consumer event reporting forms, surveys, Web
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ce.effectivehealthcare.ahrq.gov/sites/default/files/publications/files/11-0060-EF.pdf
May 01, 2011 - to the event; whether or to whom an event was reported; what
happened when an event was reported; and … What caused the patient safety event to happen?
Where did the patient safety event happen? … report the event. … to the event; whether or
to whom an event was reported; what happened when an event was reported; and … These prompts
will be designed to capture the type of event (e.g., harm event, no harm event, close
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/best-practices-survey-administration-webcast-intro.pdf
January 24, 2024 - PM ET
Webcast Technical Info
• Audio issues
• Poor Connection
• Use Q&A to submit questions
• Event … events.westat.com/sops
► Download presentation slides and view the agenda and speaker bios
on our event … site
• Event recording and slides will also be available soon at
https://www.ahrq.gov/sops/events/
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Pace.pdf
January 01, 2004 - To be this inclusive, each event may be assigned multiple codes within
each axis. … of an event characteristic as defined by the construct groupings. … event type
Axis 3.2 Event location(s)
Axis 3.3 Intent of event
Axis 3.4 Activities leading … up to event
Axis 3.5 Event cause(s)
Domain 4: Participants
Axis 4.2 Involved participant(s … Organization of event
reporting data for sense making and system
improvement.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/npsd/Data_Submission_Dashboard_Data_2023.xlsx
January 01, 2023 - tables include distributions of events and unsafe conditions reported by PSOs using Common Formats for Event … Common Formats Version DS_3
Percentage of Total Reports by Report Type DS_4
Percentage of Event … DS_5
DS_5: Percentage of Event Type by Common Formats Version
Event Type Version Frequency Percentage
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Flink.pdf
April 09, 2004 - Lessons Learned from the Evolution of Mandatory Adverse Event Reporting Systems
135
Lessons Learned … from the Evolution of
Mandatory Adverse Event Reporting Systems
Ellen Flink, C. … NYPORTS is in compliance with JCAHO’s sentinel event reporting system. … Using administrative data
to improve compliance with mandatory State event
reporting. … Sentinel event statistics.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Thomadsen.pdf
December 23, 2004 - to the actions that
led to the event. … The first box that fits
the event establishes the classification for that event. … This new
taxonomy does not assume that an event under study begins with an initiating
event, but rather … Most often, removing any one of the factors might prevent
the event. … The first tier looks for the origin of the event.
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ce.effectivehealthcare.ahrq.gov/teamstepps/simulation/traininggd.html
July 01, 2016 - The Simulation Module for Assessment of Resident Targeted Event Responses (SMARTER) approach is an event-based … All event sets consist of a trigger—the condition under which the event becomes fully activated or the … Each event set should include only one trigger event to avoid introducing too many variables and making … Explain that each slide can be chunked into two event sets, with one trigger for each event set. … Event set with trigger and distracters.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/simulation/simslides-update-62819.ppt
January 30, 2006 - TEAMSTEPPS 05.2
Mod 1 05.2 Page *
Page *
Simulation
Objectives
To know and be able to apply the Event … TEAMSTEPPS 05.2
Mod 1 05.2 Page *
Page *
Simulation
Define Event Sets
Event sets are the building … sets
Provides more than one opportunity to demonstrate behaviors
Creates reliability
Each event set … should not include more than one trigger event
Event sets can be created by breaking a clinical procedure … Don’t ask too much; you won’t like what you get
Rule of thumb: Have a key event every 1 to 2 minutes
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/modules.html
August 01, 2022 - Organizational Buy-in and Support
Module 3: Preparing for Implementation: Gap Analysis
Module 4: Event … Reporting, Event Investigation and Analysis
Analysis Module 5: Response and Disclosure
Module 6: … Generally, the CANDOR process begins with identification of an event that involves harm. … This activates initiation of coordinated post-event processes, as depicted below and described in the … Investigate and analyze an adverse event to learn from it and prevent future adverse events.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/nursing-home/resources/letter-emergency-contact.docx
May 12, 2022 - health, safety, and dignity of your loved one and are committed to protecting our residents in the event … we can contact during an emergency to share our plans for sheltering in place or evacuation in the event … We would discuss this option further with you while we prepare for such an event. … Please complete the information below for our records so we know how best to proceed in the event of
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/3-unc-webcast-mazur.pdf
January 08, 2020 - Implementation of an Event Reporting and Learning System Leads to Improvements in Patient Safety Culture … E A L T H C A R E S Y S T E M
U
N
C H E A L T H C A R E
Implementation of an Event … C A R E
U
N
C H E A L T H C A R E
Good Catch – Broad Definition
A
condition
defect
event … Celebrate improvement activities, rewards & recognition,
• Lead by example
Implementation of an Event
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apb.html
August 01, 2022 - Patient Safety Resources by Setting
Hospital
Hospital Resources
CANDOR
Event … Patient Safety News and Events
Education & Training
Resources
Event … Investigation and Analysis Guide: Appendix B
Detailed Review Timeline
Event Type:
Individuals … Timeline of Event:
March 12, 2014 (0900) RN#1 received report from ED on patient Mrs. … Page last reviewed August 2022
Page originally created April 2016
Internet Citation: Event
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ce.effectivehealthcare.ahrq.gov/patient-safety/reports/hotline/eval4.html
May 01, 2016 - report and classifies the event(s) described within it by event type, harm scale, and duration of harm … If each of these 45 visitors had completed the event reporting form, the hotline would have received … The first page of the event reporting form requires potential reporters to indicate whether they are … Patient Event Reports
During the 17 months of operation from February 2014 through June 2015, only … For comparison, spontaneous reporting from hospital-based adverse event reporting systems for health
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.doc
June 09, 2016 - Instructions
This survey asks for your opinions about patient safety issues, medical error, and event … · An “event” is defined as any type of error, mistake, incident, accident, or deviation, regardless … When an event is reported, it feels like the person is being written up, not the problem
(1
(2
(3 … No event reports
(
d.
6 to 10 event reports
(
b.
1 to 2 event reports
(
e.
11 to 20 event reports … (
c.
3 to 5 event reports
(
f.
21 event reports or more
SECTION H: Background Information
This
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.pdf
December 22, 2017 - • An “event” is defined as any type of error, mistake, incident, accident, or
deviation, regardless … When an event is reported, it feels like the person is being written up,
not the problem ......... … We are given feedback about changes put into place based on event
reports ......................... … No event reports d. 6 to 10 event reports
b. 1 to 2 event reports e. 11 to 20 event reports
… c. 3 to 5 event reports f. 21 event reports or more
SECTION H: Background Information
This information
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/resources/hospscanform.pdf
March 22, 2017 - • An “event” is defined as any type of error, mistake, incident, accident, or
deviation, regardless … When an event is reported, it feels like the person is being written up,
not the problem ......... … We are given feedback about changes put into place based on event
reports ......................... … No event reports d. 6 to 10 event reports
b. 1 to 2 event reports e. 11 to 20 event reports
… c. 3 to 5 event reports f. 21 event reports or more
SECTION H: Background Information
This information