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Showing results for "event".

61. Patient Safety Organizations: A Summary of 2014 Profiles (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/npsd/npsd-portfolios-summary-profile-2014.pdf
    January 01, 2014 - not in all event categories, and 13 PSOs in all event categories). … PSOs that collect patient safety event reports for single event types did so only for anesthesia, surgery … about 6 percent of patient safety event reports submitted by providers to PSOs. … Figure 3 shows the distribution of PSOs by type of event reports collected. Figure 3. … analyze the event with an RCA to identify the causal factor(s).

62. Patient, Family Member, and Clinician Perceptions of Disclosure of Adverse Events in Labor and Delivery | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/reports/liability/baker.html
    August 01, 2017 - Type of event seemed to affect what failures clinicians indicated should be disclosed, while type of … Last, we interviewed 12 clinicians about the common failures that can occur leading to each event. … For each event type, one of the three interviewees was a physician, and the other two were nurses. … Table 7 presents the correlation among the mean rankings for each event presented in Table 6. … If adverse event type had no effect on ranking failure, these correlations would be high.

63. PowerPoint Presentation
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module7/module7-resolution-facilitator.pptx
    August 24, 2015 - Resolution addresses the needs and concerns of patients after an adverse event. … Patients want to know what will be done to prevent the event from happening again. … Determine fair and reasonable compensation for the patient/family after an adverse event. … Potential future injuries that may result from the adverse event. … Length of time it takes to disclose the event.

64. AHRQ Quality Indicators Prioritization Worksheet Example (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c2_combo_prioritizationworksheetexample.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

65. PowerPoint Presentation
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/grand-rounds-presentation-slides.pptx
    January 01, 2014 - actually compounded the injury from the event itself. … An event report is completed, which will trigger analysis of the event. … The Investigation: to determine how the event occurred, and how to mitigate that event or even prevent … analysis of an adverse event. … place after event analysis is completed.

66. Mod01-Grand-Rounds-Slides (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/grandrounds/mod01-grand-rounds-slides.pdf
    April 01, 2016 - actually compounded the injury from the event itself. … An event report is completed, which will trigger analysis of the event. … The Investigation: to determine how the event occurred, and how to mitigate that event or even prevent … analysis of an adverse event. … ■ Host event analysis training using tools from CANDOR.

67. The PSO Privacy Protection Center | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/cpi/about/otherwebsites/psoppc.ahrq.gov/index.html
    September 01, 2018 - The PSOPPC provides technical assistance to PSOs to ensure that patient safety event data is rendered … The Common Formats promote consistent event reporting by all providers and health care organizations … assistance services, such as— Educating PSOs on the format for submitting nonidentifiable patient safety event … Rendering PSO patient safety event data nonidentifiable. … software vendors interested in implementing common definitions and reporting formats for patient safety event

68. Learning-From-Antibiotic-Adverse (doc file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/learning-from-antibiotic-adverse.docx
    June 01, 2021 - Antibiotic Use Learning From Antibiotic-Associated Adverse Events An antibiotic-associated adverse event … is any event or situation that you would not want to happen again because it either caused your patient … We use a simple four-step approach with the goal of turning a problem, near-miss, or adverse event into … Identify the antibiotic-associated adverse event. (What happened?) Step 2. … Identify the antibiotic-associated adverse event. (What happened?) 2.

69. TAKEheart Learning Community Webinars | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/takeheart/training/learning-community-webinars/index.html
    December 01, 2022 - Select to view the webinar, slides, and event summary . … Select to view the webinar, slides, and event summary . … Select to view the webinar, slides, and event summary . … Select to view the webinar, slides, and event summary . … Select to view the webinar, slides, and event summary.

70. Chapter 1. Background | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/chapter1.html
    August 01, 2022 - care experience with patient safety events that may be useful and/or actionable in a patient safety event … 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? … What is the most effective operational approach for consumers to report patient safety event information

71. Affinity-Details-Improving-Support-Women (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/affinity-details-improving-support-women.pdf
    May 01, 2021 - EVENT SUMMARY LEARNING COMMUNITY AFFINITY GROUP | SUMMARY AT-AT-GLANCE | 1 AFFINITY GROUP DETAILS … EVENT SUMMARY LEARNING COMMUNITY AFFINITY GROUP | SUMMARY AT-AT-GLANCE | 2 OVERALL EVENT THEMES … Lack of cardiologist referrals and logistical challenges were also identified by event participants … Additional Details Event slides and a recording of the event provide additional details that complement … The event slides and recording are available online at: TAKEheart.ahrq.gov

72. Development and Usability Testing of the Agency for Healthcare Research and Quality Common Formats to Capture Diagnostic Safety Events (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/topics/development-and-usability-testing-common-formats.pdf
    January 01, 2022 - Agency for Healthcare Research and Quality (AHRQ) began the de- velopment of the Common Formats for Event … Results: Estimated completion time was 30 to 90 minutes per event. … The CFER-DS also offers a definition of a diagnostic safety event using concepts pro- posed in 2 prior … Participants were asked to complete the CFER-DS to simulate event reporting for 5 cases of diagnostic … DISCUSSION Standards for diagnostic safety event reporting are necessary to advance national-level

73. Sensemaking and Learn From Defects for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-fac-guide.html
    July 01, 2023 - 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. … An antecedent describes the preceding event, condition, or cause. … The tree is an interpretation of the event.

74. Proactive Risk Assessment of Surgical Site Infections in Ambulatory Surgery Centers (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/stpra/stpra.pdf
    March 01, 2012 - ) 1 0.000103 Event 173 (0.9) Event 142 (0.3) Event 450 (0.293) Event 642 (0.2) Event 182 (0.2) Event … 173 (0.9) Event 142 (0.3) Event 450 (0.293) Event 642 (0.2) Event 30 (0.125) Event 543 (0.0325) Staff … 173 (0.9) Event 450 (0.293) Event 642 (0.2) Event 182 (0.2) Event 659 (0.18) Event 543 (0.0325) Staff … 173 (0.9) Event 450 (0.293) Event 642 (0.2) Event 182 (0.2) Event 138 (0.15) Event 543 (0.0325) Staff … Event 30 Gate 239 Event 142 Event 659 Event 138 25% reduction in noncompliance Event 30 Fail to

75. Event Investigation and Analysis Guide: Appendix E | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/ape.html
    August 01, 2022 - Patient Safety Resources by Setting Hospital Hospital Resources CANDOR Event … Patient Safety News and Events Education & Training Resources Event … As you may know, a patient care incident occurred on (insert date) involving (brief description of event … An in-depth review of the event is complete. … Page last reviewed August 2022 Page originally created April 2016 Internet Citation: Event

76. Event Investigation and Analysis Guide: Appendix F | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apf.html
    August 01, 2022 - Patient Safety Resources by Setting Hospital Hospital Resources CANDOR Event … Patient Safety News and Events Education & Training Resources Event … name), we would like you to participate in our upcoming solutions meeting related to (describe safety event … is essential to develop effective solutions to the contributing and causal factors found during our event … Page last reviewed August 2022 Page originally created April 2016 Internet Citation: Event

77. AHRQ Hospital Survey on Patient Safety Culture: Items and Dimensions (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hsops-items-composites.pdf
    February 16, 2021 - Hospital management seems interested in patient safety only after an adverse event happens. … We are given feedback about changes put into place based on event reports. C3. … Number of Events Reported (No event reports, 1 to 2 event reports, 3 to 5 event report, 6 to 10 event … reports, 11 to 20 event reports, 21 event reports or more) G1. … In the past 12 months, how many event reports have you filled out and submitted?

78. Survey on Patient Safety (facility version) (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.pdf
    November 18, 2019 - 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 .......... … 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

79. Survey on Patient Safety (facility version) (doc file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.doc
    November 15, 2019 - Safety Instructions This survey asks for your opinions about patient safety issues, medical error, and event … to answer a question, or if a question does not apply to you, you may leave your answer blank. · An “event … 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

80. II. Hotline Design and Development | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/reports/hotline/design2.html
    May 01, 2016 - The hotline had four key building blocks: A patient event reporting form. … Creating the Event Reporting Form We used multiple methods to develop the new event reporting form … A patient safety event taxonomy using drill-down (multilevel) menus is embedded in the form. … , where the event occurred). … according to the AHRQ Common Formats event type, harm scale, and duration of harm.