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Showing results for "event".

6561. The AHRQ Hospital Survey on Patient Safety Culture: A Tool to Plan and Evaluate Patient Safety Programs (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-Jones_29.pdf
      February 23, 2008 - 1.c Staff feel like their mistakes are held against them. 59 44 84 9 59 39 79 9 2.c When an event … report 63 51 79 9 49 28 70 11 1 to 2 event reports 16 4 34 8 24 11 33 7 3 to 5 event reports 13 … 5 31 8 15 8 31 6 6 to 10 event reports 5 0 6 2 7 0 14 4 11 to 20 event reports 2 0 6 2 4 0 17 5 … 21 event reports or more 1 0 6 2 2 0 7 2 a Standard deviation. … The same item in 2007 asked respondents how many event reports have you filled out and submitted.

6562. Presentation: Program Overview
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/engaging-srexec-slides.pptx
      January 01, 2017 - 5 Our ventilator-associated event (VAE) rates have definitely not been zero. … know Provide relevant information Staff turnover rate Number of mechanical ventilation cases Safety event

6563. Relationship Between Patient Harm and Reported Medical Errors in Primary Care: A Report from the ASIPS Collaborative (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-West_102.pdf
      March 31, 2008 - associated tests, associated medications, participants, outcome(s), individual(s) who discovered the event … , provider, or practice because the attributes of that event were so unusual. … Multiple roles could be involved in any single error event. … Event reporting to a primary care patient safety reporting system: A report from … Mixed methods analysis of medical error event reports: a report from the ASIPS Collaborative.

6564. Presentation: Program Overview
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/vae/vaesurveillance-slides.pptx
      January 01, 2017 - Presentation: Program Overview Ventilator-Associated Event Surveillance AHRQ Safety Program for Mechanically … EVENT TYPE GENDER LOCATION PATIENT ID FIRST NAME LAST NAME EVENT VAE M ICU 1234 Mickey Mouse PVAP VAE

6565. Seeking the Right Balance: Addressing Behaviors That Undermine a Culture of Safety (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2015-materials/teamstepps-monthly-webinar-sept2015.pdf
      January 01, 2015 - Case: “Whistling a Tune” The following event was reported to you (an authority figure) through your … electronic event reporting system. … Behaviors that Undermine Safety Culture Slide 15 What % of the time would someone report the event … to a responsible party or through an established event reporting system?

6566. TeamSTEPPS for Code Blue Teams: Piloting SBAR & CUS for Interprofessional Team Education
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2015-materials/teamstepps-monthly-webinar-april2015.pptx
      January 01, 2015 - about issues related to teamwork and communication Quality improvement committee reviews Data from event … Progress 2012 – Began collecting data on teamwork and communication using 5 questions included on our event … TeamSTEPPS for Code Blue Teams Slide ‹#› Measuring Progress Limitations Not a validated questionnaire Event

6567. Tools for Reducing Central Line-Associated Blood Stream Infections (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/hai/clabsi-tools/clabsi-tools-revised.pdf
      January 01, 2013 - CLABSI Event Report Template Appendix 8. CLABSI Investigation Nurse Letter Appendix 9. … Use the Event Report Template and Nurse Letter If a CLABSI occurs on your unit, your team should … The CLABSI Event Report Template (Appendix 7) catalogs defects that contribute to a CLABSI. … Central Line-Associated Bloodstream Infection (CLABSI) Event. … device policies Empower nurses to stop procedures Use the Central Line Maintenance Audit Form Use the Event

6568. Making Information Technology a Team Player in Safety: The Case of Infusion Devices (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Nemeth.pdf
      January 01, 2002 - Manufacturer and User Device Experience (MAUDE) database that serves as a clearinghouse for adverse event … A fourth phase reviewed the MAUDE database for all adverse event reports related to the infusion pumps … Interface Design for Infusion Devices 329 Relationship between studies of devices and adverse event … Attempts have been made to create adverse event reporting systems to capture and analyze incidents … Adverse event reports suggest that human–computer interactions are the “root cause” of the majority

6569. Resource List - AHRQ Ambulatory Surgery Center Survey (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/asc-resource-list.pdf
      April 01, 2023 - Staff can use this decision tree when analyzing an error or adverse event in an organization to help … identify how human factors and systems issues contributed to the event. … Staff can use this decision tree when analyzing an error or adverse event in an organization to help … identify how human factors and systems issues contributed to the event. … Leadership Response to a Sentinel Event: Respectful, Effective Crisis Management 5.

6570. Module-5-Slides (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-5-slides.pdf
      December 31, 2022 - content of their presentation with the exception of: Amy Miller, MD, PhD, faculty for this educational event … using the EMR experts will respond to questions submitted in advance by persons registering for the event … Please answer the survey questions as you leave the event today

6571. Leveraging Existing Assessments of Risk Now (LEARN) Safety Analysis: A Method for Extending Patient Safety Learning (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-woods_79.pdf
      May 30, 2008 - performance-shaping factors and child-specific risk factors by 2 applying different accident category/event … The fail points are categorized according to the type of event, using the categories, performance-shaping … care processes in both hospital-based and ambulatory medical care.5 Step 3.1: Accident categories/event … Accident categories/event types 1. … Anatomy of a patient safety event. A taxonomy for pediatric patient safety.

6572. Medical Injury Identification Using Hospital Discharge Data (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Layde.pdf
      January 01, 2003 - public attention on the issue of patient safety and highlighted the need for better data on adverse event … information collected for other purposes tend to provide a more complete description of the adverse event … Not surprisingly, most of these systems have produced adverse event reports at rates substantially lower … In the event of a question, the physicians reviewed the entire medical record for the patient admission … due to operations or procedures 48.0% 50.3% 44.9% 40.3% % of Adverse event or medical injury

6573. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/vae/vaesurveillance-facguide.docx
      January 01, 2017 - Prevention Bundle Slide Title and Commentary Slide Number and Slide Title Slide Ventilator-Associated Event … Surveillance SAY: This module will focus on ventilator-associated event surveillance and how it can … Type text] [Type text] AHRQ Safety Program for Mechanically Ventilated Patients Ventilator-Associated Event … Surveillance results can give providers a way to monitor and improve this care by connecting the dots from the event … unit staff can spend time focusing on what went wrong and how to fix it rather than debate whether the event

6574. TeamSTEPPS 2.0, Module 4: Leading Teams (Instructor's Guide) (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module4/igleadership.pdf
      March 10, 2014 - DISCUSSION: • What event necessitated the need for the huddle? … Debriefs include: • Accurate recounting and documentation of key events; • Analysis of why the event … Debriefs can be a brief (about 3 minutes or less) team event, typically initiated and facilitated by … preprocedure briefing checklist – Included the patient in the “timeout” – Held debrief to recap event … Use of these tools leads to gaining a shared model or understanding of a situation or event (i.e., shared

6575. Dear [NURSES NAMES]-- (doc file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/clabsitools/clabsitoolsap9.doc
      December 11, 2012 - Because the event occurred more than 48 hours from the time of line insertion, it is clear that this

6576. Dear [NURSES NAMES]-- (doc file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/clabsitools/clabsitoolsap8.doc
      December 11, 2012 - Because the event occurred more than 48 hours from the time of line insertion, it is clear that this

6577. Paul Tedrick (doc file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/connecting-dots-transcript.doc
      October 08, 2013 - So, you can see then that this graph obviously shows you that event reporting is clearly a strength for … improve reporting is that the frontline worker feels as if they get feedback about what happens to event … if you do not give people feedback about what happens with event reports, and if you do not engage them … in the process of understanding those event reports. … So, if we take an example, when an event is reported, it feels like the person is being written up, not

6578. CVC Insertion Risk Factors: (doc file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/clabsitools/clabsitoolsap7.doc
      September 03, 2013 - Insertion Risk Factors: Central Venous Catheter-Associated Laboratory-Confirmed Blood Stream Infection Event

6579. Impact of Staff-Led Safety Walk Rounds (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Montgomery_42.pdf
      March 05, 2008 - • Cumbersome event reporting system for physicians (a user-friendly format already existed for nurses … throughout the hospital—is an increase in the number of staff who know how to report a near miss or actual event … rounds, members of Team Safety noticed that few staff members knew how to report a near miss or actual event … Is there anything that could be done to prevent the next adverse event or to address your safety concern

6580. Patient Monitors in Critical Care: Lessons for Improvement (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Drews_16.pdf
      January 01, 2003 - To make matters worse, in the case of an unexpected and potentially life-threatening event, the cognitive … on fast pattern recognition processes or on slow, cognitively demanding problem analysis. 3 o Event … An expanded event horizon is available, and the subjective time pressure is less than at the lower levels … Data/event integration • Marking events as an explanation for changes in vital signs. … Information, such as event markers and trend data, often is either not available or not easily accessible