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Showing results for "event".

121. Patient Safety Learning Pilot: Narratives from the Frontlines (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Kellie_30.pdf
     April 21, 2008 - Initially, errors are detected by hospital staff who complete Event Registration and Event Discovery … via an email containing a link to the event. … to the prior event, and the causal codes are shared. … and how we pay attention to the reasons for such an event. … the collective understanding of the event

122. Exhibit 12. Probability of an intervention reducing the risk of surgical site infection (SSI) by interventions targeting component failure points individually | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/research/findings/final-reports/stpra/stpraexh12.html
     April 01, 2018 - References for Fault Tree Model Probability Estimates References Event Original probability … noncompliance 75% reduction in noncompliance Original Probability of SSI 0.0044       Event … 0.0938 0.0625 0.0313 Gate 239 Antibiotics related failure 0.3000 0.2250 0.1500 0.0750 Event … 142 Staff not well-trained in infection control 0.3000 0.2250 0.1500 0.0750 Event 659 Glove … puncture 0.1800 0.1350 0.0900 0.0450 Event 138 Fail to remove watch/jewelry/fake nails 0.1500

123. AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Sensemaking and Learn from Defects
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/sensemaking.pptx
     May 01, 2017 - from Defects Sensemaking Overview4 A conversation among members of an organization involved in an event … /issue The purpose is to reduce the ambiguity about the event/issue—literally to make sense of it Each … person brings their experience of that event/issue to the discussion The conversation is the mechanism … from Defects 13 Learning From Defects Overview Health care providers are adept at reacting to an event … The attributes of medical event-reporting systems: Experience with a prototype medical event-reporting

124. Patient and Family Engagement | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/hai/cusp/modules/patient-family-engagement/notes.html
     September 01, 2013 - Immediate Response to an Adverse Event 4 Slide 24. … How to Communicate About an Adverse Event 6 Slide 26. … What if an Adverse Event Occurs on the Unit? … event, and the care provided as a result of the event … of emotions when an adverse event occurs.

125. Affinity-Details-Coping-Staff-Challenges (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/affinity-details-coping-staff-challenges.pdf
     September 16, 2020 - EVENT SUMMARY LEARNING COMMUNITY AFFINITY GROUP | SUMMARY AT-AT-GLANCE | 1 AFFINITY GROUP DETAILS … Format • A moderated panel discussion with five panelists, with additional input from the 100 event … EVENT SUMMARY LEARNING COMMUNITY AFFINITY GROUP | SUMMARY AT-AT-GLANCE | 2 ASSESSING THE CURRENT … STATUS OF CR PROGRAM OPERATION STATUS AT-A-GLANCE Current State Future State Participants in this event … —Tina Miller EVENT SUMMARY LEARNING COMMUNITY AFFINITY GROUP | SUMMARY AT-AT-GLANCE |

126. Hospital SOPS Translation Information | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/sops/international/hospital/translators.html
     October 01, 2014 - Hospital management seems interested in patient safety only after an adverse event happens. … When an event is reported, it feels like the person is being written up, not the problem. … The term "rating" can be used instead of "grade." ) Number of Events Reported (No event reports, … 1 to 2 event reports, 3 to 5 event reports, 6 to 10 event reports, 11 to 20 event reports, 21 event reports … In the past 12 months, how many event reports have you filled out and submitted?

127. Asthma 1 Measure Calculation Steps (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/pqmp/toolkits/flow-diagrams.pdf
     March 11, 2021 - DEC_TOTAL_MEM_LEVEL Identify payer details associated with most recent qualifying event Sum event … DEC_IDENT_CE Concatenate denominator month tables 10) AST1_OUT.DENOMINATOR_RAW_DATA Deduplicate: 1 event … payer/member combos that exist in the denominator Deduplicate so that there is only 1 numerator event … asthma (ie - is in the denominator) 6If a qualified member has no numerator events during a month, the event

128. Strategies to Better Manage Lipids – Statin Pearls
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/evidencenow/heart-health/strategies-to-better-manage-lipids.pptx
     November 01, 2016 - Recommendation Grade Adults ages 40-75 years with no symptoms or history of CVD and a calculated 10-year CVD event … dyslipidemia, diabetes, hypertension, or smoking) They have a calculated 10-year risk of a cardiovascular event … of 10% or greater Identification of dyslipidemia and calculation of 10-year CVD event risk requires … Recommendation Grade Adults ages 40-75 years with no symptoms or history of CVD and a 10-year CVD event … statin use may be beneficial for the primary prevention of CVD events in some adults with a 10-year CVD event

129. Implementation of an Event Reporting and Learning System Leads to Improvements in Patient Safety Culture at UNC Medical Center - Intro (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/1-unc-webcast-intro.pdf
     December 18, 2019 - Implementation of an Event Reporting and Learning System Leads to Improvements in Patient Safety Culture … at UNC Medical Center - Intro Implementation of an Event Reporting and Learning System Leads to Improvements

130. Patient and Family Engagement for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/pf-engagement-fac-guide.html
     July 01, 2023 - Engaging after an adverse event. Engaging in planning and design. … Immediately after an adverse event, care providers: Provide care. … event, and the care provided as a result of the event. … a number of emotions when an adverse event occurs. … Rarely does an adverse event occur as a result of intent.

131. Blood and Blood Product Dashboard | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/npsd/data/dashboard/blood.html
     October 01, 2023 - blood product involved, type of blood product by residual harm to the patient, stage of process where event … originated, and stage of process where event originated by residual harm to the patient.

132. Medication or Other Substance Dashboard | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/npsd/data/dashboard/medication.html
     October 01, 2023 - type of incorrect dose, type of incorrect dose by residual harm to the patient, stage of process where event … originated, and stage of process where event originated by residual harm to the patient.

133. Appendix A. Recommendations for Ideal Consumer Reporting Systems (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/hotline/hotline-appendixa.pdf
     May 11, 2016 - care experience with patient safety events that may be useful and/or actionable in a patient safety event … Information collected from consumers should include where a patient safety event occurred; what contributed … to the event; whether or to whom the event was reported; what happened when the event was reported; … and the impacts or consequences of the event. … What is the most effective operational approach for consumers to report patient safety event information

134. Final Report: Translating simulation-based team leadership training into patient-level outcomes (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/2024-01/fernandez-rosenman-report.pdf
     January 01, 2024 - (s) Define (Event) Triggers Identify observable, clinically appropriate triggers for each event … event. … metric that were confusing, poorly defined, or assigned to an inappropriate event. … Event-based approach to measurement (EBAM) 6. … Event-based approach to training (EBAT). Int. J. Aviat. Psychol. 1998;8(3):209-221. 37.

135. Fallpxtool1A (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallpxtoolkit/fallpxtool1a.docx
     January 01, 2004 - An “event” is defined as any type of error, mistake, incident, accident, or deviation, regardless of … When an event is reported, it feels like the person is being written up, not the problem 1 2 3 4 … We are given feedback about changes put into place based on event reports 1 2 3 4 5 2. … 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

136. Major Study Shows Significant Drop in In-Hospital Adverse Event Rates Pre-COVID | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/news/newsletters/e-newsletter/822.html
     July 01, 2022 - Newsletter AHRQ News Now Major Study Shows Significant Drop in In-Hospital Adverse Event … Now Events Major Study Shows Significant Drop in In-Hospital Adverse Event … Today's Headlines: Major Study Shows Significant Drop in In-Hospital Adverse Event Rates Pre-COVID … Major Study Shows Significant Drop in In-Hospital Adverse Event Rates Pre-COVID The rates of in-hospital … July 2022 Internet Citation: Major Study Shows Significant Drop in In-Hospital Adverse Event

137. C1 Prioritization Worksheet (xls file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheet.xlsx
     July 01, 2016 - disagree/low) Barrier Assessment (indicate Yes or No) Volume of Cases at Risk Cost of Single Event … G H I J K L M N O P Q R List of PSIs/IQIs/PDIs Own Rate National Comparator Annual volume of this event … Anticipated average cost for one case with this event The total annual cost of this event to our organization … Anticipated cost to investigate/ implement new process is less than annual cost of event Anticipated … with established organizational goals and priorities • Regulatory • Value-based purchasing • Sentinel event

138. AHRQ Guide Helps Virginia Osteopathic Medicine School Improve Health Education | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/news/newsroom/case-studies/cp30504.html
     October 01, 2014 - integral part of the Virginia College of Osteopathic Medicine's (VCOM) first annual Mini Medical School event … This event was a collaborative effort on behalf of the faculty and students to improve health care education … Niyati Sheth, organizer of the event and second-year medical student at VCOM, says, "AHRQ materials contained … This event was the beginning of something incredible for VCOM and this region. … I am very grateful for the help AHRQ has provided in making this free event possible, and I very much

139. USER GUIDE: COVID-19 Vaccination Tracking Tool for Use in Skilled Nursing Facilities (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/user-guide-covid-19-vaccination-tracking-tool-nursing-facilities.pdf
     July 01, 2022 - Select Adverse Event (Reaction) to 1st Dose. … Select Adverse Event (Reaction) to 2nd Dose. … Adverse Event (Reaction) to any COVID-19 Vaccine Dose? … Select Adverse Event (Reaction) to 1st Dose. … Select Adverse Event (Reaction) to 2nd Dose.

140. Views of Emergency Medicine Trainees on Adverse Events and Negligence: Survey Results from an Emergency Medicine Training Program in a Regional Health Care System Following the National Standard of Care (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Shah_99.pdf
     March 23, 2008 - Quality of care standards are especially salient when a trainee is faced with a patient adverse event … Yet, in adverse event situations in which care standards do not exist, rules with which to proceed are … Statements addressing a negligence-based event made up less than half the responses (11/28). … How many times have you not told a patient about an adverse event that affected them? 5. … Our study specifically studied the term “adverse event.”