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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2020.pdf
January 01, 2020 - TYPE, category of event (EVENT TYPE), and INITIAL
REPORT DATE. … concern (CATEGORY ASSOCIATED WITH
EVENT OR UNSAFE CONDITION [EVENT TYPE]) as a percentage of all EVENT … (Event Types)
Report Type by Event Type
Report Type by Event Type
Report Type by Event Type (Data … Extent of Harm by Event Type (Data Table)
Event Type by Extent of Harm
Event Type by Extent of Harm … Originated
Stage Event Originiated
Stage Event Originated by Extent of Harm
Stage Event Originiated
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ce.effectivehealthcare.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/exh3.html
August 01, 2022 - Information about the event flows to system users: primary system audience of consumers; and other potential … Type of event: harm event, no harm event, near miss. … Event details: who, what, where, etc. (Use structured input in a common reporting format.) … Reporting can be at any time, during or after the event. … real-time reporting, but caution reporters that the system is not a substitute for calling 911 in the event
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Encinosa.pdf
January 01, 2003 - What Happens After a Patient Safety Event? … Medical Expenditures and Outcomes in Medicare
423
What Happens After a Patient Safety Event? … PSI refers to a patient safety event occurring. … , with $288 in extra outpatient payments attributable
to the event (P < 0.05). … PSI refers to a patient safety event
occurring.
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ce.effectivehealthcare.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/chapter5.html
August 01, 2022 - Second, the system hub will interact with the health care facility where an event took place. … The event itself: the type of event; where (in the process of care) and when it occurred; who was involved … Narrative of event, including contributory factors. … These prompts will be designed to capture the type of event (e.g., harm event, no harm event, close call … Individuals will be able to submit reports at any time during or after the event.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2019.pdf
January 01, 2019 - Event-specific Reports
The Common Formats include event-specific modules pertaining to nine patient … (EVENT ID); and the REPORT TYPE, category of event (EVENT TYPE), and INITIAL
REPORT DATE. … of different EVENT TYPES. … concern (CATEGORY ASSOCIATED WITH
EVENT OR UNSAFE CONDITION [EVENT TYPE]) as a percentage of all EVENT … Types)
Report Type by Event Type
Extent of Harm by Event Type
Event Type by Extent of Harm
Extent
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2021.pdf
January 01, 2021 - TYPE, category of event (EVENT TYPE), and INITIAL
REPORT DATE. … concern (CATEGORY ASSOCIATED WITH
EVENT OR UNSAFE CONDITION [EVENT TYPE]) as a percentage of all EVENT … (Event Types)
Report Type by Event Type
Report Type by Event Type
Report Type by Event Type (Data … Extent of Harm by Event Type (Data Table)
Event Type by Extent of Harm
Event Type by Extent of Harm … Originated
Stage Event Originiated
Stage Event Originated by Extent of Harm
Stage Event Originiated
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ce.effectivehealthcare.ahrq.gov/news/newsroom/case-studies/202104.html
October 01, 2021 - or potential adverse event, and officials estimate 85 patients were spared the additional harm of not … “It’s all about how to communicate an adverse event or a potential adverse event promptly and candidly … "Our goal is to notify the patient and family within 60 minutes of an event," Pelletreau explained. … When an unexpected event occurs, those situations are tracked by a core management team consisting of … “CANDOR is absolutely the right approach for all involved in an adverse event,” Pelletreau said.
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ce.effectivehealthcare.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/chapter3.html
August 01, 2022 - , and communication or coordination issues that contributed to the event. … from the time the event occurred ("real time") to well after the event, once they have had time to heal … A total of 74 patient safety event reporting systems were identified. … had a family member who had experienced a patient safety event. … the event.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/module1-overview.pptx
May 19, 2016 - Unsafe Condition
Near Miss
No Harm Event
CANDOR
Event
Actual harm to patient
Potential patient harm … A CANDOR event is an event that involves unexpected patient harm. … cause of a harm event. … the event. … of a CANDOR Event.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/2024-01/aparasu-report.pdf
January 01, 2024 - date
Cases
Controls
Controls chosen at
event date
Event date for cases Anticholinergic use … were
captured 30 days before the event date using Medicare Part D data. … days before the event date using Medicare Part D data. … As before, the earlier date of occurrence was considered the
event date. … A fall is a major event in the life of an older person.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module6/module6-care-for-caregiver.pptx
May 01, 2011 - (s) involved in the event. … The reliving of the event is also known as a “tripping” or “triggering” event and can occur when the … The event might produce feelings of internal inadequacy, either because the event occurred or because … Responding to multiple “whys” about the event.
Interacting with many different event responders. … the post-event period.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Nguyen.pdf
May 01, 2003 - Physician Event Reporting: Training the Next Generation of Physicians
353
Physician Event Reporting … and unsafe situations remains extremely
low, despite the increased access to and use of electronic event … We implemented an electronic, Web-based event reporting system at five
University of California medical … Our
experience validates that of others; specifically, physician event reporting is a
largely elusive … Change how event reporting systems are used
Traditionally, event reporting was a way to warn institutional
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/module5-response-disclosure-notes.pptx
August 21, 2015 - and of the impact of the event on their care. … Within 60 minutes after the CANDOR event is identified. … What are the implications of the event for the patient’s health?
Why did the event happen? … the system” for the event. … Can I see a copy of the event analysis?
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-ptsafety-and-covid-19.pdf
November 01, 2021 - event, etc.). … Descriptive Text About the Event Referencing COVID-19
Fall Event COVID-19 precautions cause a delay … Other Event
Too many things do. … Details of Event or Unsafe Condition, and Contributing Factor(s) for Event were analyzed during a pilot … Number of Records by the Category(s) Associated with the Event or Unsafe Condition
Category of Event
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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/Ulep.pdf
January 01, 2004 - the event form to match the type of event being
reported. … the event? … An
electronic event management system can accommodate all parties who need to be
aware of an event … Common understanding of event definitions. 1 2 3 4
2. … Consideration #5—Open Event Reporting
NR U R VR
1.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheet.pdf
June 29, 2016 - Anticipated
average cost for
one case with this
event
The total annual
cost of this event
to … Anticipated
average cost for
one case with this
event
The total annual
cost of this event
to … Anticipated
average cost for
one case with this
event
The total annual
cost of this event
to … Anticipated
average cost for
one case with this
event
The total annual
cost of this event
to … Anticipated
average cost for
one case with this
event
The total annual
cost of this event
to
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/mod5-disclosure-checklist.pdf
April 01, 2016 - ■ 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. … event. … ■ Consider ways to involve patients in post-event learning.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/learning-antibiotic-adverse-events-form.docx
November 01, 2019 - Use
Learning From Antibiotic-Associated Adverse Events
An antibiotic-related adverse event … is any event or situation involving the prescription or administration of antibiotics that you would … Identify the antibiotic-associated adverse event.
2. … Identify the negative and positive factors associated with the adverse event. … Adverse Event
Negative Factor
Positive
Factor
Patient Factors
(related to clinical or emotional
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ce.effectivehealthcare.ahrq.gov/hai/cusp/modules/identify/notes.html
December 01, 2012 - into a near-miss event. … of "why's" to reach the root causes of the event. … the event from reaching the patient. … Harm that did not happen—No harm event.
Event did not reach the patient—Near-miss event. … The tree is an interpretation of the event.
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ce.effectivehealthcare.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/chapter4.html
August 01, 2022 - What caused the patient safety event to happen?
Where did the patient safety event happen? … What impact did the patient safety event have? … What were the consequences of the patient safety event? … to the event; whether or to whom an event was reported; what happened when an event was reported; and … the impacts or consequences of the event.