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Showing results for "event".

81. New Challenge Competition Launched To Update and Re-Create TeamSTEPPS Videos | Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/news/newsletters/e-newsletter/813.html
    May 01, 2022 - records abstracted and analyzed using the Medicare Patient Safety Monitoring System, changes in adverse event … In one article  (PDF, 1 MB), researchers tested the usability of AHRQ’s draft Common Formats Event Reporting … first step toward implementation of a new and comprehensive set of data elements for diagnostic safety event

82. Hospital Survey on Patient Safety Culture: User's Guide (pdf file)
    talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/userguide/hospitalusersguide.pdf
    July 01, 2018 - No event reports  d. 6 to 10 event reports  b. 1 to 2 event reports  e. 11 to 20 event reports …  c. 3 to 5 event reports  f. 21 event reports or more SECTION H: Background Information This information … We are given feedback about changes put into place based on event reports. C3. … Number of Events Reported (No event reports, 1 to 2 event reports, 3 to 5 event report, 6 to 10 event … reports, 11 to 20 event reports, 21 event reports or more) G1.

83. Selected Best Practices and Suggestions for Improvement (pdf file)
    talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4n_combo_iqi-mortalityreview-bestpractices.pdf
    May 20, 2016 - 3 days of discharge ∗ Death associated with drug reaction ∗ Death associated with adverse drug event … • Find ways to prevent recurrence of the event if preventable. … • Recommendations are made to prevent recurrence of a similar event. … results are reviewed regularly (quarterly or biannually) to determine if there is any recurrence of the event

84. AcademyHealth’s Annual Research Meeting: An Opportunity to Connect, Engage, and Inspire | Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/news/blog/ahrqviews/academy-health-2022-meeting.html
    May 01, 2022 - ARM is a premier event for health services research (HSR).  … AHRQ is one of the participating Federal agencies supporting this important event, and it’s an honor

85. AHRQ Safety Program for Perinatal Care: Labor and Delivery Unit Safety Umbilical Cord Prolapse (doc file)
    talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/tool_cord-prolapse.docx
    May 01, 2017 - facilitating a safe delivery by offering logic and a clear focus during what can often be a chaotic event … · A unit can decide its approach to debriefing events based on seriousness of event, expertise available … · Informal debriefings by clinical team immediately following the event using an approach that does … prolapse diagnosis, awareness and monitoring of time since diagnosis, and discussing next steps in the event

86. TeamSTEPPS Pocket Guide (pdf file)
    talkingquality.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/teamstepps-pocket-guide.pdf
    May 01, 2023 - .......................11 Effective Team Leadership ..............................12 Effective Team Event … Team Leadership Page 13 Effective Team Event Tools Sharing the Plan y Brief—Short session prior to … I-PASS Team Leadership Multi-Team System forPatient Care Effective Team Leadership Effective Team Event … I-PASS Team Leadership Multi-Team System forPatient Care Effective Team Leadership Effective Team Event

87. The End of the Public Health Emergency Refocuses the Urgency to Improve Healthcare Quality | Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/news/blog/ahrqviews/public-health-emergency-refocus.html
    May 01, 2023 - England Journal of Medicine that estimated 1 in 4 people hospitalized are at risk of a patient safety event … Trends in adverse event rates in hospitalized patients. JAMA  2022 Jul 12;328(2):173-83.

88. Maine Groups Improve Care for Patients with Intellectual/Developmental Disabilities | Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/news/newsroom/case-studies/202201.html
    January 01, 2022 - Pezzullo described their Safe Table event as a protected forum where participants can feel comfortable … After an IDD Safe Table event held in August 2020 for primary care physicians, attendee feedback forms

89. AHRQ National Scorecard on Hospital-Acquired Conditions: Updated Baseline Rates and Preliminary Results 2014-2016 (pdf file)
    talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/natlhacratereport-rebaselining2014-2016_0.pdf
    January 01, 2016 - The use of these five sets of charts also eliminated the need to use 2005-2006 Medicare adverse event … Measures used to estimate the national HAC rate HAC Type Source Measure Adverse Drug Event MPSMS … Associated With Hip Joint Replacements MPSMS Adverse Event Associated With Knee Joint Replacements … for all patients for which the MPSMS data are used, we follow these steps: • Multiply the adverse event … MPSMS Femoral Artery Procedures Puncture for Catheter Angiographic 21,538 0.72 MPSMS Adverse Event

90. Methods To Estimate the Baseline 2010 PFP National Hospital-Acquired Condition Rate | Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/hai/pfp/methods.html
    December 01, 2017 - Condition Rate Partnership for Patients Hospital-Acquired Conditions Source Measure Adverse Drug Event … population, rather than as a rate for the subpopulation that has the opportunity to experience the adverse event … for each of the 21 HACs for all patients for which the MPSMS data are used, we multiply the adverse event … (rounded)  (updated June 2014) 4,757,000   145 Ideally, we would have estimated the adverse event

91. Federal Interagency Workgroup--Diagnostic Safety: November Meeting Summary (pdf file)
    talkingquality.ahrq.gov/sites/default/files/wysiwyg/topics/dx-safety-workgroup-meeting-notes-nov2022.pdf
    March 01, 2023 - • Common Formats for Event Reporting – Diagnostic Safety o Released the Common Formats for Event

92. TeamSTEPPS Fundamentals Course: Module 4. Leading Teams | Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/teamstepps/instructor/fundamentals/module4/igleadership.html
    March 01, 2019 - Discussion: What event necessitated the need for the huddle? … Analysis of why the event occurred, what worked, and what did not work. … Debriefs can be a brief (about 3 minutes or less) team event, typically initiated and facilitated by … Held debrief to recap event and share lessons learned. … Use of these tools leads to gaining a shared model or understanding of a situation or event (i.e., shared

93. AHRQ Safety Program for Perinatal Care: Labor and Delivery Unit Safety Shoulder Dystocia (doc file)
    talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/tool_shoulder-dystocia.docx
    May 01, 2017 - facilitating a safe delivery by offering logic and a clear focus during what can often be a chaotic event … · A unit can decide its approach to debriefing events based on seriousness of event, expertise available … · Informal debriefings by clinical team immediately following event using an approach that does not … www.safehealthcareforeverywoman.org · Resource name: Process for Reviewing Severe Maternal Morbidity Event

94. CAUTI Sustainability: Embedding CAUTI Policies, Using Data to Monitor Proress and Hardwiring CUSP Principles | Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/hai/cauti-tools/archived-webinars/cauti-sustainability-slides.html
    December 01, 2017 - at unexpected events, data results, and outcomes to determine all of the underlying causes of the event … Event Analysis Team notification – Nurse Manager, Medical Director, and Frontline staff notification … – email and huddle Infection Prevention Council report out Slide 66 Event Analysis Tool Image … : Screen shot of a CAUTI Event Analysis form. … Slide 80 Identifying Defects: Defects Can Come From Many Different Sources Staff feedback Event

95. TeamSTEPPS Video Debrief Guide: Huddle in Emergency Department (pdf file)
    talkingquality.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/video/huddle-emergency-dept-guide.pdf
    August 31, 2023 - Lessons Learned A huddle helps teams improve performance and enhance safety when preparing for an event

96. Resource List - AHRQ Ambulatory Surgery Center Survey (pdf file)
    talkingquality.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/asc-resource-list.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. … 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 5.

97. Events | Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/news/events/index.html
    November 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 …

98. In Pandemic’s Wake, We Must Recommit to Patient and Workforce Safety | Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/news/blog/ahrqviews/patient-workforce-safety.html
    March 01, 2023 - The event was attended by 800 people online and 200 in person—in my view a strong signal of consensus … I was glad for AHRQ to take the lead in organizing the November 14 event.

99. Module 3: Best Practices in Fall Prevention—Slide Presentation | Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-3/slides.html
    September 01, 2017 - Components A brief staff gathering, interdisciplinary when possible, that immediately follows a fall event … Convenes within 15 minutes of the fall event. … Led by clinician(s) responsible for patient/resident during the fall event. … Slide 46: Root Cause Analysis After an injurious fall, collect data to reconstruct the event and

100. Best Practices in Fall Prevention
     talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module3/module3_slides_best-practices.pptx
     June 16, 2017 - Components A brief staff gathering, interdisciplinary when possible, that immediately follows a fall event … Convenes within 15 minutes of the fall event Led by clinician(s) responsible for patient/resident during … the fall event Involves the patient/resident whenever possible in the environment where the patient/ … Review Tool 3N ‹#› Root Cause Analysis After an injurious fall, collect data to reconstruct the event