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Showing results for "event".

81. Candor-Impguide (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/candor-impguide.pdf
    April 01, 2016 - A CANDOR event is defined as an event that involves unexpected harm (physical, emotional, or financial … A CANDOR event is defined as an event that involves unexpected harm (physical, emotional, or financial … After the event is identified as a CANDOR event, CANDOR System Activation occurs and triggers the start … reporting system, event investigation, and event analysis. … (see Adverse Event [Reasonable Care] and Adverse Event [Unreasonable Care]).

82. Patient and Family Engagement | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/hai/cusp/modules/patient-family-engagement/sl-pat-fam.html
    September 01, 2013 - Immediate Response to an Adverse Event 4 Slide 24. … Next Steps in Responding to an Adverse Event 5 Slide 25. … How to Communicate About an Adverse Event 6 Slide 26. … Immediate Response to an Adverse Event 4 Care for the patient. … Next Steps in Responding to an Adverse Event 5 Investigation.

83. Workplace Safety Resource List (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/workplace-safety/workplace_safety_resource_list.pdf
    October 01, 2021 - /resources/patient-safety-topics/sentinel-event/sentinel- event-alert-newsletters/sentinel-event-alert … /sentinel-event-alert-newsletters/sentinel-event-alert-59-physical-and-verbal-violence-against-health-care-workers … / https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/sentinel-event-alert-newsletters … /resources/patient-safety-topics/sentinel-event/sentinel-event-alert-newsletters/sentinel-event-alert … https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/sentinel- event-alert-newsletters

84. Reporting of Adverse Drug Events: Examination of a Hospital Incident Reporting System (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Desikan.pdf
    March 01, 2002 - The RMEES database contains the following information: event date, floor, event number, event description … After pharmacy staff receives adverse drug event data from RMEES, they further categorize the event … adverse drug event rates. … types, and event reasons. … Scatter plot of RMEES potential adverse drug event rates versus preventable adverse drug event rates

85. Sensemakingnotes (doc file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/identify/sensemakingnotes.docx
    August 08, 2012 - into a near-miss event. … of "why's" to reach the root causes of the event. … the event from reaching the patient. … that did not happen—No harm event · Event did not reach the patient—Near-miss event We then ask why … The tree is an interpretation of the event.

86. Chapter 2. ST-PRA Development | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/research/findings/final-reports/stpra/stpra2.html
    April 01, 2018 - probabilities of event combinations. … Event 660 Patient fails to notice infection during home care. … Event 642 Staff fail to protect patient effectively. … Event 450 Obese, but not diabetic, patient (30 ≤BMI <40). … Event 182 Fail to administer indicated antibiotics.

87. Improving Workplace Safety in Hospitals: A Resource List for Users of the AHRQ Workplace Safety Supplemental Item Set (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/workplace-safety-resources.pdf
    May 01, 2023 - /resources/patient-safety-topics/sentinel-event/sentinel- event-alert-newsletters/sentinel-event-alert … /sentinel-event-alert-newsletters/sentinel-event-alert-59-physical-and-verbal-violence-against-health-care-workers … / https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/sentinel-event-alert-newsletters … /resources/patient-safety-topics/sentinel-event/sentinel-event-alert-newsletters/sentinel-event-alert … / https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/sentinel-event-alert-newsletters

88. Prioritization Worksheet (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheetinstructions.pdf
    June 05, 2016 - In column E, “Volume of Cases at Risk,” indicate the annual volume of each PSI, IQI, and/or PDI event … Column F, “Cost of Single Event,” indicates the average cost to your organization of one event. … We have not included cost estimates for a single event directly in the worksheet, as you may want to … Has your organization recently experienced negative press regarding an event? … What would this look like in the community if you had an event in your organization?

89. Learn-From-Defects-Facilitator-Guide (doc file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.docx
    May 01, 2017 - Sensemaking tools supply a systematic approach to event reporting. … of “why’s” to reach the root causes of the event. … the event from reaching the patient. … did not happen—No-harm event Event did not reach the patient—Near-miss event We then ask why this consequence … The tree is an interpretation of the event.

90. Chapter 3. Risk-Informed Interventions | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/research/findings/final-reports/stpra/stpra3.html
    April 01, 2018 - The targeted event(s) for the intervention. A description of the proposed intervention. … For example, assuming that the top event SSI occurs, the criticality of basic event A is the probability … that the top event is a result of basic event A. … For example, "Event 642 Fail to protect the patient effectively,"ranked as the most critical unique event … Because the targeted event is comprised of multiple, related issues, the intervention can be designed

91. Developing a Veterans Health Administration (VHA) Serious Injury Surveillance System that Includes Adverse Event Hospitalizations (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Campbell.pdf
    January 01, 2003 - Developing a Veterans Health Administration (VHA) Serious Injury Surveillance System that Includes Adverse Event … Developing a Veterans Health Administration (VHA) Serious Injury Surveillance System that Includes Adverse Event … The medical care costs for these injury and adverse event hospital discharges were obtained from the … Results: Over the study time frame, 153,153 injury and adverse event discharges occurred, with more … Trends in VHA injury and adverse event hospitalizations: by discharge frequency Table 2.

92. Executive Summary | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/summary.html
    August 01, 2022 - The TEP includes experts in patient safety, patient safety event reporting systems, health care delivery … care experience with patient safety events that may be useful and/or actionable in a patient safety event … What is the most effective operational approach for consumers to report patient safety event information … 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.

93. Identify Defects Through Sensemaking | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/hai/cusp/modules/identify/identify.html
    December 01, 2012 - The purpose is to reduce the ambiguity about the event/issue—literally to make sense of it. … Each person brings his or her experience of that event/issue to the discussion. … Antecedent Event Root Causes Root Cause Classification Codes Recovery Return to Contents … Providers must also correct the factors that contribute to an event. … The attributes of medical event-reporting systems: Experience with a prototype medical event-reporting

94. Sensemaking and Learn From Defects for Perinatal Safety | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-slides.html
    July 01, 2023 - Each person brings their experience of that event/issue to the discussion. … At the top of the tree and at the top row is the discovery event. … The discovery event addresses what happened. … Providers must also correct the factors that contribute to an event. … The attributes of medical event-reporting systems: Experience with a prototype medical event-reporting

95. Generic Dashboard Data 2023 (xls file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/npsd/Generic_Dashboard_Data_2023.xlsx
    January 01, 2023 - of Event/Unsafe Condition by Event Type Gen_3 Location of Event/Unsafe Condition by Report Type … _6 Near Miss Prevention Actions within Event Types Gen_7 Extent of Harm by Event Type, Age, and … Type by Year Report Year Event Type Event Count Total Yearly Events Percent 2010 Blood or Blood Product … Gen_3 Location of Event/Unsafe Condition by Event Type Event Type Location of event/unsafe condition … Gen_5 Contributing Factors by Event Type Event Type Contributing Factor(s) for Event Event Count Total

96. Event Investigation and Analysis Guide: Appendix C | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apc.html
    August 01, 2022 - Patient Safety Resources by Setting Hospital Hospital Resources CANDOR Event … Patient Safety News and Events Education & Training Resources Event … This format helps to utilize the information found in the investigation to understand why the event occurred … Page last reviewed August 2022 Page originally created April 2016 Internet Citation: Event

97. Sensemaking and Learn from Defects for Perinatal Safety (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.pdf
    May 01, 2017 - Sensemaking tools supply a systematic approach to event reporting. … 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- Slide 13 Sensemaking … The tree is an interpretation of the event.

98. Equipment and Supplies | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/research/shuttered/toolkitchecklist/surgetkit3.html
    July 01, 2018 - Ramp-Up Description: Once the catastrophic event occurs, facility opening efforts will be underway … Timeframe: As soon as the catastrophic event occurs, through implementation of planned arrangements … Review/Replanning Description: In the unfortunate event that a terrorist incident or disaster occurs … Buses: In the unlikely event that the local transit authority is unwilling to provide buses, contracts … Ramp-Up Description: As necessitated by a catastrophic event, the surge facility must progress from

99. Implementation Guide for the CANDOR Process: Appendix B | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/impguide/apb.html
    August 01, 2022 - CANDOR Implementation Team Leader Influential staff person who may have experienced a second-victim event … Event Reporting, Investigation, And Analysis Team     Event Reporting, Investigation, and Analysis … Team Lead Implements the event reporting, investigation, and analysis processes; reports to the CANDOR … Implementation Team Leader Director of Risk Management Event Reporting, Investigation, and Analysis … Team Assists the Team Lead with developing, educating, and implementing the event reporting, investigation

100. Staff Safety Assessment
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/identify/sensemaking.pptx
     January 01, 2006 - /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 … Sensemaking 17 Learning From Defects Overview Health care providers are adept at reacting to an event … 25 Sensemaking Tools To Learn From Defects 26 Causal Coding: Eindhoven Model6 20 separate event … The attributes of medical event-reporting systems: Experience with a prototype medical event-reporting