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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
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June 01, 2022 - safety, quality and risk managers, clinicians, and others use Common Formats to collect patient safety event
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January 01, 2024 - learning algorithms have the potential to improve the categorization of medication-related patient safety event
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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
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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
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November 01, 2018 - Have a Back-up Plan
Consider what you can do in the event that providers don’t cooperate—or if cooperation
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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
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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
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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
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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