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  1. talkingquality.ahrq.gov/patient-safety/news-events/index.html
    March 01, 2024 - Skip to main content An official website of the Department of Health and Human Services Careers Contact Us Español FAQs Search all AHRQ sites Search small Search Menu …
  2. talkingquality.ahrq.gov/sites/default/files/wysiwyg/topics/DxSafety-March2019-MeetingNotes.pdf
    March 08, 2019 - • Partnership with VA to look at data, trends, and solution for delay in treatment event type.
  3. talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/rapid-response/rapidresponse_facguide.pdf
    May 01, 2017 - and expectations for the response, uniform expectations for documentation of the rapid response event … • An event that requires a team response. … The L&D unit can decide its approach to learning from defects based on seriousness of event, expertise
  4. talkingquality.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/tools/ts-tpq-questionnaire.pdf
    May 31, 2023 - My supervisor/manager provides opportunities to discuss the unit’s performance after an event.
  5. talkingquality.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/safe-electronic-fac-guide.html
    July 01, 2023 - cases of perinatal death or permanent disability reported to The Joint Commission under its sentinel event-reporting … From Defects Say: A unit can decide its approach to debriefing events based on seriousness of event … Informal debriefings can be used by the clinical team immediately following a near miss or actual adverse event
  6. talkingquality.ahrq.gov/talkingquality/translate/compare/choose/standard.html
    January 01, 2023 - While “zero-tolerance” is implied by the term “never event,” this may not be language that the public
  7. talkingquality.ahrq.gov/news/newsroom/press-releases/national-advisory-council-meeting.html
    March 01, 2021 - Closed captioning will be provided during this event.
  8. talkingquality.ahrq.gov/news/newsletters/e-newsletter/899.html
    February 01, 2024 - Speakers at the event, sponsored by AHRQ and the National Institutes of Health, highlighted major drivers
  9. talkingquality.ahrq.gov/ncepcr/communities/pbrn/registry/machine-machine-mankind-interface-pbrn.html
    August 11, 2014 - Supports advance features such as sensor support, behavior pattern recognition, event-driven behavior
  10. talkingquality.ahrq.gov/diagnostic-safety/resources/index.html
    March 01, 2024 - Common Formats for Event Reporting–Diagnostic Safety (CFER–DS) Page last
  11. talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety_facguide.pdf
    May 01, 2017 - facilitating a safe delivery by offering logic and a clear focus during what can often be a chaotic event … of hemorrhage, or patient preferences that may limit the use of blood and blood products in the event … culture that supports debriefing by the clinical team immediately after a near miss, an adverse event … o A unit can decide its approach to debriefing events based on the seriousness of the event, expertise
  12. talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/updatedhacrateinfo.pdf
    June 01, 2014 - Discharges— Based on 2010 Baseline) 2012 PFP Measured HACs per 1,000 Discharge s Adverse Drug Event
  13. talkingquality.ahrq.gov/teamstepps/readiness/index.html
    August 01, 2015 - Objective information can originate from a variety of sources, including adverse event and near-miss … For continued success, the organization needs to view the culture change as a process rather than an event
  14. talkingquality.ahrq.gov/patient-safety/news-events/psaw-2020/index.html
    December 01, 2023 - As the Nation's patient safety agency, AHRQ supports this event to increase awareness about patient safety
  15. talkingquality.ahrq.gov/cahps/index.html
    Associations and Paths for Quality Improvement – Research Meeting Summary Read the event
  16. talkingquality.ahrq.gov/news/newsroom/press-releases/national-advisory-meeting-july-14.html
    July 01, 2021 - Closed captioning will be provided during this event.
  17. talkingquality.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/rapid-response/rapid-response-fac-guide.html
    July 01, 2023 - responding and expectations for the response, uniform expectations for documentation of the rapid response event … An event that requires a team response. … The L&D unit can decide its approach to learning from defects based on seriousness of event, expertise
  18. talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/tool_obhemorrhage.docx
    May 01, 2017 - risk of hemorrhage, or patient preferences that may limit the use of blood and blood products in the event … · Unit can decide its approach to debriefing events based on seriousness of event, expertise available … · Informal debriefings by clinical team immediately following event should use an approach that does
  19. talkingquality.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/community-pharmacy/pharmacy-resources.pdf
    May 01, 2023 - Calls And Hazardous Conditions https://psnet.ahrq.gov/resources/resource/32494 This new sentinel event … 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. … news-and-multimedia/fact-sheets/facts-about-do- not-use-list/ In 2001, The Joint Commission issued a Sentinel Event
  20. talkingquality.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursinghome-resourcelist.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. … Leadership Response to a Sentinel Event: Respectful, Effective Crisis Management http://www.ihi.org/ … Culture Just In Time Toolkits: Recipes for Staffing Transformation Leadership Response to a Sentinel Event … Leadership Response to a Sentinel Event: Respectful, Effective Crisis Management 4.

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