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  1. talkingquality.ahrq.gov/sites/default/files/2024-01/quintana-report.pdf
    January 01, 2024 - By examining the overlays for clustering similar events, we further conformed to the validity of our event … Navigation Errors Observed in Scenarios 1-3 4.3 Usability Discussion The aggregated event timelines … steadily declined in progression as scenarios were completed but remained the most frequently observed event
  2. talkingquality.ahrq.gov/funding/grantee-profiles/grtprofile-fairbanks.html
    December 01, 2023 - 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 …
  3. talkingquality.ahrq.gov/talkingquality/translate/presentation.html
    April 01, 2016 - 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 …
  4. talkingquality.ahrq.gov/research/findings/evidence-based-reports/makinghcsafer.html
    June 01, 2022 - safety, quality and risk managers, clinicians, and others use Common Formats to collect patient safety event
  5. talkingquality.ahrq.gov/patient-safety/settings/ambulatory/reduce-readmissions.html
    December 01, 2023 - 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 …
  6. talkingquality.ahrq.gov/news/newsletters/e-newsletter/898.html
    January 01, 2024 - learning algorithms have the potential to improve the categorization of medication-related patient safety event
  7. talkingquality.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/state-of-science.pdf
    April 02, 2020 - adverse events so they can review the medical record to determine if an actual or potential adverse event … Systems without EHR capabilities can use other data sources (e.g., selective reviews, event reports) … Consensus building for development of outpatient adverse drug event triggers. … natural language processing for classification tasks in the field of incident reporting and adverse event … Integrating natural language processing expertise with patient safety event review committees to improve
  8. talkingquality.ahrq.gov/news/newsletters/e-newsletter/890.html
    November 01, 2023 - within 48 hours of presentation and in 13 percent of hospitalizations patients experienced an adverse event
  9. talkingquality.ahrq.gov/news/newsletters/e-newsletter/886.html
    October 01, 2023 - 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 …
  10. talkingquality.ahrq.gov/patient-safety/settings/hospital/candor/videos/planning.html
    August 01, 2022 - 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 …
  11. talkingquality.ahrq.gov/patient-safety/news-events/psaw-2022/index.html
    July 01, 2022 - 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 …
  12. talkingquality.ahrq.gov/patient-safety/news-events/psaw-2021/index.html
    July 01, 2022 - 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 …
  13. talkingquality.ahrq.gov/healthsystemsresearch/virtual-roundtable-discussion/index.html
    March 01, 2023 - 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 …
  14. talkingquality.ahrq.gov/talkingquality/plan/gain-trust.html
    November 01, 2018 - Have a Back-up Plan Consider what you can do in the event that providers don’t cooperate—or if cooperation
  15. talkingquality.ahrq.gov/news/newsroom/case-studies/201601.html
    January 01, 2018 - 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 …
  16. talkingquality.ahrq.gov/antibiotic-use/long-term-care/improve/intervention.html
    June 01, 2021 - 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 …
  17. talkingquality.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/medoffice-resourcelist.pdf
    April 01, 2023 - Close Calls and Hazardous Conditions https://psnet.ahrq.gov/resources/resource/32494 This 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. … disrupting the normal flow of clinic practice, clinics agree on a standard protocol to follow for each event … www.jointcommission.org/assets/1/18/Do_Not_Use_List_9_14_18.pdf The Joint Commission issued a Sentinel Event
  18. talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module3/module3_pu-bestpractices_slides.pptx
    November 20, 2014 - To Do a Skin Assessment Video Clip of Skin Assessment 7 Skin Assessment Frequency Not a one-time event
  19. talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module5/ebsitmonitor.pdf
    January 01, 2013 - consider situation monitoring to be the TeamSTEPPS component most likely to prevent a patient safety event
  20. talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/b4_combo_documentationcoding.pdf
    March 15, 2016 - than the number of flagged cases (PPV <1) (e.g., individuals were coded as having a patient safety event … when no event actually occurred), there is a problem with false positives. … removes cases that arrived at the hospital with a condition that would be coded as a patient safety event … History of event. … procedure itself and those that are unintended and are therefore considered a complication or unexpected event

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