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Showing results for "event".

121. Sensemaking and Learn From Defects for Perinatal Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/perinatal-care/modules/teamwork/learn-from-defects-slides.html
     May 01, 2017 - Each person brings their experience of that event/issue to the discussion. … At the top of the tree and at the top row is the discovery event. … The discovery event addresses what happened. … Providers must also correct the factors that contribute to an event. … The attributes of medical event-reporting systems: Experience with a prototype medical event-reporting

122. Equipment and Supplies | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/shuttered/toolkitchecklist/surgetkit3.html
     July 01, 2018 - Description: The equipment and supplies team must lay the groundwork for procurement prior to a surge event … Ramp-Up Description: Once the catastrophic event occurs, facility opening efforts will be underway … Timeframe: As soon as the catastrophic event occurs, through implementation of planned arrangements … Review/Replanning Description: In the unfortunate event that a terrorist incident or disaster occurs … Ramp-Up Description: As necessitated by a catastrophic event, the surge facility must progress from

123. Prioritization Worksheet (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheetinstructions.pdf
     June 05, 2016 - In column E, “Volume of Cases at Risk,” indicate the annual volume of each PSI, IQI, and/or PDI event … Column F, “Cost of Single Event,” indicates the average cost to your organization of one event. … We have not included cost estimates for a single event directly in the worksheet, as you may want to … Has your organization recently experienced negative press regarding an event? … What would this look like in the community if you had an event in your organization?

124. Sensemaking and Learn From Defects for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/perinatal-care/modules/teamwork/learn-from-defects-fac-guide.html
     May 01, 2017 - Sensemaking tools supply a systematic approach to event reporting. … of "why's" to reach the root causes of the event. … the event from reaching the patient. … Harm that did not happen—No-harm event. Event did not reach the patient—Near-miss event. … The tree is an interpretation of the event.

125. Learn-From-Defects-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.docx
     May 01, 2017 - Sensemaking tools supply a systematic approach to event reporting. … of “why’s” to reach the root causes of the event. … the event from reaching the patient. … did not happen—No-harm event Event did not reach the patient—Near-miss event We then ask why this consequence … The tree is an interpretation of the event.

126. Workplace Safety Resource List (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/workplace-safety/workplace_safety_resource_list.pdf
     October 01, 2021 - /resources/patient-safety-topics/sentinel-event/sentinel- event-alert-newsletters/sentinel-event-alert … /sentinel-event-alert-newsletters/sentinel-event-alert-59-physical-and-verbal-violence-against-health-care-workers … / https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/sentinel-event-alert-newsletters … /resources/patient-safety-topics/sentinel-event/sentinel-event-alert-newsletters/sentinel-event-alert … https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/sentinel- event-alert-newsletters

127. Implementation Guide for the CANDOR Process: Appendix B | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/impguide/apb.html
     August 01, 2022 - CANDOR Implementation Team Leader Influential staff person who may have experienced a second-victim event … Event Reporting, Investigation, And Analysis Team     Event Reporting, Investigation, and Analysis … Team Lead Implements the event reporting, investigation, and analysis processes; reports to the CANDOR … Implementation Team Leader Director of Risk Management Event Reporting, Investigation, and Analysis … Team Assists the Team Lead with developing, educating, and implementing the event reporting, investigation

128. Appendix A. Recommendations for Ideal Consumer Reporting Systems | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/hotline/appa.html
     May 01, 2016 - care experience with patient safety events that may be useful and/or actionable in a patient safety event … Information collected from consumers should include where a patient safety event occurred; what contributed … to the event; whether or to whom the event was reported; what happened when the event was reported; … and the impacts or consequences of the event. … What is the most effective operational approach for consumers to report patient safety event information

129. Event Investigation and Analysis Guide: Appendix A | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apa.html
     August 01, 2022 - Event Investigation and Analysis Guide: Appendix A Five Whys In this example, there is only … Event Summary:   The wrong concentration of potassium (K+) was used in the compounding of TPN.

130. Improving Workplace Safety in Hospitals: A Resource List for Users of the AHRQ Workplace Safety Supplemental Item Set (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/workplace-safety-resources.pdf
     May 01, 2023 - /resources/patient-safety-topics/sentinel-event/sentinel- event-alert-newsletters/sentinel-event-alert … /sentinel-event-alert-newsletters/sentinel-event-alert-59-physical-and-verbal-violence-against-health-care-workers … / https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/sentinel-event-alert-newsletters … /resources/patient-safety-topics/sentinel-event/sentinel-event-alert-newsletters/sentinel-event-alert … / https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/sentinel-event-alert-newsletters

131. Using Socio-Technical Probabilistic Risk Assessment (ST-PRA) to Assess Risk and Improve Patient Safety and Reliability in Health Care Systems | Agency for Healthcare Research and Quality
     www.ahrq.gov/es/hai/patient-safety-resources/advances-in-hai/hai-article19.html
     June 01, 2014 - Cut sets are unique event combinations that lead to the occurrence of the top-level event. … probabilities of event combinations. … For example, assuming that the top-level event occurs, the criticality of basic-level event A is the … probability that the top-level event is a result of basic-level event A, thereby indicating the fundamental … paths leading to the occurrence of the top-level event.

132. Using Socio-Technical Probabilistic Risk Assessment (ST-PRA) to Assess Risk and Improve Patient Safety and Reliability in Health Care Systems | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/patient-safety-resources/advances-in-hai/hai-article19.html
     June 01, 2014 - Cut sets are unique event combinations that lead to the occurrence of the top-level event. … probabilities of event combinations. … For example, assuming that the top-level event occurs, the criticality of basic-level event A is the … probability that the top-level event is a result of basic-level event A, thereby indicating the fundamental … paths leading to the occurrence of the top-level event.

133. Patient Safety Organizations: A Summary of 2014 Profiles (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/npsd-portfolios-summary-profile-2014.pdf
     January 01, 2014 - not in all event categories, and 13 PSOs in all event categories). … PSOs that collect patient safety event reports for single event types did so only for anesthesia, surgery … about 6 percent of patient safety event reports submitted by providers to PSOs. … Figure 3 shows the distribution of PSOs by type of event reports collected. Figure 3. … analyze the event with an RCA to identify the causal factor(s).

134. Final Progress Report: Incident Reporting Practices in Nursing Homes (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/castle-report.pdf
     January 01, 2025 - This study found numerous barriers and few facilitators to adverse event reporting. … State Policies Associated with Adverse Event Reporting in Nursing Homes. … The attributes of medical event-reporting systems: Experience with a prototype medical event reporting … ‡ Most (1) to least (20) important barrier to event reporting. Note. … (%) Only when a minor event occurs (%) Only when a major event occurs (%) Always,

135. Sensemaking and Learn from Defects for Perinatal Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.pdf
     May 01, 2017 - Sensemaking tools supply a systematic approach to event reporting. … of “why’s” to reach the root causes of the event. … the event from reaching the patient. … Harm that did not happen—No-harm event • Event did not reach the patient—Near- Slide 13 Sensemaking … The tree is an interpretation of the event.

136. Patient and Family Engagement for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/pf-engagement-fac-guide.html
     July 01, 2023 - Engaging after an adverse event. Engaging in planning and design. … Immediately after an adverse event, care providers: Provide care. … event, and the care provided as a result of the event. … a number of emotions when an adverse event occurs. … Rarely does an adverse event occur as a result of intent.

137. Staff Safety Assessment
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/identify/sensemaking.pptx
     January 01, 2006 - /issue The purpose is to reduce the ambiguity about the event/issue -literally to make sense of it Each … person brings their experience of that event/issue to the discussion The conversation is the mechanism … Sensemaking 17 Learning From Defects Overview Health care providers are adept at reacting to an event … 25 Sensemaking Tools To Learn From Defects 26 Causal Coding: Eindhoven Model6 20 separate event … The attributes of medical event-reporting systems: Experience with a prototype medical event-reporting

138. Identify Defects Through Sensemaking, Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/modules/identify/notes.html
     December 01, 2012 - into a near-miss event. … of "why's" to reach the root causes of the event. … the event from reaching the patient. … Harm that did not happen—No harm event. Event did not reach the patient—Near-miss event. … The tree is an interpretation of the event.

139. NPSD Chartbooks | Agency for Healthcare Research and Quality
     www.ahrq.gov/npsd/data/chartbook/index.html
     February 01, 2025 - 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

140. Medication Dashboard Data 2022 (xls file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/Medication_Dashboard_Data_2022.xlsx
     January 01, 2022 - tables include the relative frequency of reports by incorrect action, by the stage of process where the event … Originated Med_6 Stage Event Originated by Extent of Harm Med_7 https://www.ahrq.gov … Med_6 Med_6: Stage Event Originated Stage of Process Percentage Frequency Total Unknown 41.1% 51,579 … 2.7% 3,330 125,648 Storing 1.6% 1,956 125,648 Purchasing 0.2% 247 125,648 Med_7 Med_7: Stage Event … Originated by Extent of Harm Stage Event Originated No Harm Percentage No Harm Frequency Harm Percentage