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preventiveservices.ahrq.gov/cpi/about/otherwebsites/qsrs.ahrq.gov/index.html
March 01, 2021 - Features
The QSRS:
Offers an expanded array of adverse event measures. … standardized definitions and algorithms, consistent with those used by the AHRQ Common Formats for Event
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hsops2-pt2_transition_apx.pdf
September 01, 2019 - (F3R)
Hospital management seems interested in
patient safety only after an adverse event
happens. … (C3)
We are given feedback about changes put into
place based on event reports. … (G1)
(No event reports, 1 to 2, 3 to 5, 6 to 10, 11 to 20,
21 event reports or more)
45% 44% 1% … (C3)
We are given feedback about
changes put into place based on
event reports. … (G1)
(No event reports, 1 to 2, 3 to 5, 6
to 10, 11 to 20, 21 event reports
or more)
45% 44% 1%
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preventiveservices.ahrq.gov/news/newsroom/press-releases/significant-patient-safety-improvement.html
July 01, 2022 - Researchers found significant decreases in in-hospital adverse event rates for heart attack, heart failure … In the observed data for 2010 and 2019, adverse event rates fell 36 percent for heart attack patients … After adjustment, the relative risk of experiencing an adverse event diminished for all five patient
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/SOPS-Hospital-Survey-2.0-English-05.18.21.docx
June 09, 2016 - Instructions
This survey asks for your opinions about patient safety issues, medical error, and event … injuries or adverse events resulting from the processes of healthcare delivery.
· A “patient safety event … When an event is reported in this unit, it feels like the person is being written up, not the problem … In this unit, we are informed about changes that are made based on event reports
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2
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4
5
9 … Hospital management seems interested in patient safety only after an adverse event happens
1
2
3
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-factraining-guide.pdf
December 15, 2016 - Nursing home staff generally do a good job of investigating
and following up after an adverse event … It is more difficult for
staff to identify which residents are at risk for a future
adverse event … high risk or had a recent change in risk, would we do things
differently to intervene before the event … The questions in each Self-Assessment are tailored to the On-Time
adverse event being addressed. … Discussion
questions are tailored to the On-Time adverse event being
addressed.
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospitalsurvey2-items.pdf
August 01, 2019 - When an event is reported in this unit, it feels like the person is being written up, not the problem … In this unit, we are informed about changes that are made based on event reports. … Hospital management seems interested in patient safety only after an adverse event happens.
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospitalresourcelist.pdf
January 01, 2019 - • Investigate and analyze an adverse event to learn from it and prevent future adverse
events. … /primers/primer/13
This AHRQ primer provides background information on voluntary patient safety event … of event reporting, and how event reports can be used to improve safety. … Staff can use this decision tree when analyzing
an error or adverse event in an organization to help … identify how human factors and systemic
issues contributed to the event.
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_3_communication.pptx
July 01, 2023 - Please note the technique is the focus, as the event is not a hypertensive event.
10
Assessing the … The event can be real, loosely based on real events, or totally made up. … Please note that the scenario does not relate to a severe hypertensive event. … Sentinel Event Data: Root Causes by Event Type, 2004-2015. 2016. https://hcupdate.files.wordpress.com … /2016/02/2016-02-se-root-causes-by-event-type-2004-2015.pdf.
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_3-communication-speaker-notes.pdf
July 01, 2023 - Please note the technique is the focus, as the event is not a hypertensive event.
16
Hospital AIM … The event can
be real, loosely based on real events, or totally made up. … Please note that the scenario does not relate to a severe hypertensive event. … Sentinel
Event Data: Root Causes by Event Type, 2004‐2015. 2016. … https://hcupdate.files.wordpress.com/2016/02/2016‐02‐se‐root‐causes‐
by‐event‐type‐2004‐2015.pdf.
3
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/topics/public-notes-meeting-summary-031121.pdf
July 22, 2021 - IHS • Enhanced Adverse Event Reporting Capabilities: IHS Safety
Tracking and Response (I-STAR) system … Future goal is to align the platform with AHRQ’s Common Formats
for Event Reporting.
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_3-communication-speaker-notes.pdf
July 01, 2023 - In the event of a hemorrhage, it’s recommended to always call‐out when blood loss
exceeds 1,000 mL. … Please note the technique is the focus, as the event is not an obstetric hemorrhage event.
16
Hospital … Please be aware
that the scenario is unrelated to an obstetric hemorrhage event. … The event can
be real, loosely based on real events, or totally made up. … Sentinel
Event Data: Root Causes by Event Type, 2004‐2015. 2016.
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_3_communication.pptx
July 01, 2023 - Please note the technique is the focus, as the event is not an obstetric hemorrhage event.
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Assessing … Please be aware that the scenario is unrelated to an obstetric hemorrhage event. … The event can be real, loosely based on real events, or totally made up. … Sentinel Event Data: Root Causes by Event Type, 2004-2015. 2016. https://hcupdate.files.wordpress.com … /2016/02/2016-02-se-root-causes-by-event-type-2004-2015.pdf.
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preventiveservices.ahrq.gov/hai/tools/mvp/vae.html
December 01, 2017 - Tools To Support Monitoring VAEs and Outcome Measures
Ventilator-Associated Event Data Collection Tool … - HTML Version of Slide Presentation ; Facilitator Guide - Word , 3 MB)
Ventilator-Associated Event
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/resources/tools/cauti-surveillance/assessment.docx
March 01, 2017 - while having an indwelling urinary catheter in place or removed within the 2 calendar days prior to the event … References:
Adapted from Centers for Disease Control and Prevention (CDC), Urinary Tract Infection (UTI) Event
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preventiveservices.ahrq.gov/teamstepps-program/curriculum/team/tools/debrief.html
December 01, 2023 - Analysis of why the event occurred, what worked, and what did not work. … Debriefs can be a short (about 3 minutes or less) team event, typically initiated and facilitated by
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preventiveservices.ahrq.gov/npsd/data/chartbook/index.html
September 01, 2023 - provide an overview of the patient safety data captured in the NPSD through the AHRQ Common Formats for Event … They examine data for topics that cut across the multiple modules in the AHRQ Common Formats for Event
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-factraining-slides.pptx
November 01, 2016 - Specifications and
EMR Vendors
Functional specifications are available for On-Time reports for each adverse event … Investigate the root cause when an adverse event occurs. … The questions in each Self-Assessment worksheet are tailored to the On-Time adverse event being addressed … discussion to help the Change Team decide how to use the On-Time reports to help prevent the adverse event
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preventiveservices.ahrq.gov/evidencenow/projects/heart-health/evidence/cholesterol.html
March 01, 2021 - CVD) in adults aged 40 to 75 years, with at least one CVD risk factor and an increased risk of a CVD event … The USPSTF recommended discussing statin use in similar patients with more moderate risk of a CVD event … cardiovascular disease (CVD) and for those who have one or more CVD risk factors with a calculated 10-year CVD event
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospital-v2-resourcelist.pdf
April 01, 2023 - of event reporting, and ways event reports can be used to improve safety. … • Investigate and analyze an adverse event to learn from it and prevent future adverse
events. … Staff can use this decision tree when analyzing
an error or adverse event in an organization to help … identify how human factors and systemic
issues contributed to the event. … Leadership Response to a Sentinel Event: Respectful, Effective Crisis Management
3.
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preventiveservices.ahrq.gov/npsd/data/dashboard/generic.html
September 01, 2023 - This dashboard includes information for event and report types organized by year (annual trends), examines