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Showing results for "event".

141. AHRQ Pediatric Quality Indicators Prioritization Worksheet (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/c1_pdi_prioritizationworksheet.pdf
     June 05, 2016 - Indicators Toolkit Prepared by RAND and UHC for AHRQ Tool C.1 Volume of Cases at Risk Cost of Single Event … E F G H I J K L M N O P Q R List of PDIs Own Rate National Comparator Annual volume of this event … Anticipated average cost for one case with this event The total annual cost of this event to … organization Anticipated cost to investigate/ implement new process is less than annual cost of event … established organizational goals and priorities • Regulatory • Value-based purchasing • Sentinel event

142. Developing a Taxonomy for Coding Ambulatory Medical Errors: A Report from the ASIPS Collaborative (pdf file)
     www.ahrq.gov/downloads/pub/advances/vol2/pace.pdf
     January 01, 2004 - To be this inclusive, each event may be assigned multiple codes within each axis. … of an event characteristic as defined by the construct groupings. … event type Axis 3.2 Event location(s) Axis 3.3 Intent of event Axis 3.4 Activities leading … up to event Axis 3.5 Event cause(s) Domain 4: Participants Axis 4.2 Involved participant(s … Organization of event reporting data for sense making and system improvement.

143. Developing a Taxonomy for Coding Ambulatory Medical Errors: A Report from the ASIPS Collaborative (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Pace.pdf
     January 01, 2004 - To be this inclusive, each event may be assigned multiple codes within each axis. … of an event characteristic as defined by the construct groupings. … event type Axis 3.2 Event location(s) Axis 3.3 Intent of event Axis 3.4 Activities leading … up to event Axis 3.5 Event cause(s) Domain 4: Participants Axis 4.2 Involved participant(s … Organization of event reporting data for sense making and system improvement.

144. 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.

145. Best Practices for Administering SOPS® Surveys Users (Webcast): Introduction (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/best-practices-survey-administration-webcast-intro.pdf
     January 24, 2024 - PM ET Webcast Technical Info • Audio issues • Poor Connection • Use Q&A to submit questions • Event … events.westat.com/sops ► Download presentation slides and view the agenda and speaker bios on our event … site • Event recording and slides will also be available soon at https://www.ahrq.gov/sops/events/

146. Taxonomic Guidance for Remedial Actions (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Thomadsen.pdf
     December 23, 2004 - to the actions that led to the event. … The first box that fits the event establishes the classification for that event. … This new taxonomy does not assume that an event under study begins with an initiating event, but rather … Most often, removing any one of the factors might prevent the event. … The first tier looks for the origin of the event.

147. C1 Prioritization Worksheet (xls file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/c1_pdi_prioritizationworksheet.xlsx
     May 25, 2016 - disagree/low) Barrier Assessment (indicate Yes or No) Volume of Cases at Risk Cost of Single Event … C D E F G H I J K L M N O P Q R List of PDIs Own Rate National Comparator Annual volume of this event … Anticipated average cost for one case with this event The total annual cost of this event to our organization … Anticipated cost to investigate/ implement new process is less than annual cost of event Anticipated … with established organizational goals and priorities • Regulatory • Value-based purchasing • Sentinel event

148. Communication and Optimal Resolution (CANDOR) Toolkit | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules.html
     August 01, 2022 - Organizational Buy-in and Support Module 3: Preparing for Implementation: Gap Analysis Module 4: Event … Reporting, Event Investigation and Analysis Analysis Module 5: Response and Disclosure Module 6: … Generally, the CANDOR process begins with identification of an event that involves harm. … This activates initiation of coordinated post-event processes, as depicted below and described in the … Investigate and analyze an adverse event to learn from it and prevent future adverse events.

149. Patient and Family Engagement for Perinatal Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/pf-engagement-slides.html
     July 01, 2023 - Discuss how to communicate an adverse event to a patient and family members. … Engaging after an adverse event. Engaging in planning and design. … Slide 18: Immediate Response to an Adverse Event 4 Care for the patient. … Document the event in the medical record. … Slide 21: Next Steps in Responding to an Adverse Event 6 Investigation.

150. Final Progress Report: Adverse Event-Directed Analysis in Ambulatory Primary Care (pdf file)
     www.ahrq.gov/sites/default/files/2024-10/kennerly-ballard-report.pdf
     January 01, 2024 - Final Progress Report: Adverse Event-Directed Analysis in Ambulatory Primary Care Adverse Event-Directed … Key Words: trigger tool, adverse event, patient safety, ambulatory care 2 PURPOSE The purpose of … is and why they think it is an adverse event. … Description of a computerized adverse drug event monitor using a hospital information system. … Adverse drug event trigger tool: a practical methodology for measuring medication related harm.

151. 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

152. AHRQ Hospital Survey on Patient Safety Culture: Items and Dimensions (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/userguide/hospital-survey-items.pdf
     July 25, 2017 - Hospital management seems interested in patient safety only after an adverse event happens. … 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 reports, 6 to 10 event … reports, 11 to 20 event reports, 21 event reports or more) G1. … In the past 12 months, how many event reports have you filled out and submitted?

153. C2 Prioritization Worksheet Example (xls file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/c2_pdi_prioritizationworksheetexample.xlsx
     May 25, 2016 - disagree/low) Barrier Assessment (indicate Yes or No) Volume of Cases at Risk Cost of Single Event … C D E F G H I J K L M N O P Q R List of PDIs Own Rate National Comparator Annual volume of this event … Anticipated average cost for one case with this event The total annual cost of this event to our organization … Anticipated cost to investigate/ implement new process is less than annual cost of event Anticipated … with established organizational goals and priorities • Regulatory • Value-based purchasing • Sentinel event

154. Patient, Family Member, and Clinician Perceptions of Disclosure of Adverse Events in Labor and Delivery | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/liability/baker.html
     August 01, 2017 - Type of event seemed to affect what failures clinicians indicated should be disclosed, while type of … event had little effect on what failures patients and family members indicated should be disclosed. … Last, we interviewed 12 clinicians about the common failures that can occur leading to each event. … Table 7 presents the correlation among the mean rankings for each event presented in Table 6. … If adverse event type had no effect on ranking failure, these correlations would be high.

155. AHRQ Guide Helps Virginia Osteopathic Medicine School Improve Health Education | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/cp30504.html
     October 01, 2014 - integral part of the Virginia College of Osteopathic Medicine's (VCOM) first annual Mini Medical School event … This event was a collaborative effort on behalf of the faculty and students to improve health care education … Niyati Sheth, organizer of the event and second-year medical student at VCOM, says, "AHRQ materials contained … This event was the beginning of something incredible for VCOM and this region. … I am very grateful for the help AHRQ has provided in making this free event possible, and I very much

156. TAKEheart Learning Community Webinars | Agency for Healthcare Research and Quality
     www.ahrq.gov/takeheart/training/learning-community-webinars/index.html
     December 01, 2022 - Select to view the webinar, slides, and event summary . … Select to view the webinar, slides, and event summary . … Select to view the webinar, slides, and event summary . … Select to view the webinar, slides, and event summary. … Select to view the webinar, slides, and event summary .

157. Implementation of an Event Reporting and Learning System Leads to Improvements in Patient Safety Culture at UNC Medical Center-Mazur (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/3-unc-webcast-mazur.pdf
     January 08, 2020 - Implementation of an Event Reporting and Learning System Leads to Improvements in Patient Safety Culture … E A L T H C A R E S Y S T E M U N C H E A L T H C A R E Implementation of an Event … C A R E U N C H E A L T H C A R E Good Catch – Broad Definition A condition defect event … Celebrate improvement activities, rewards & recognition, • Lead by example Implementation of an Event

158. Patient and Family Engagement | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/modules/patient-family-engagement/sl-pat-fam.html
     September 01, 2013 - Immediate Response to an Adverse Event 4 Slide 24. … Next Steps in Responding to an Adverse Event 5 Slide 25. … How to Communicate About an Adverse Event 6 Slide 26. … Immediate Response to an Adverse Event 4 Care for the patient. … Next Steps in Responding to an Adverse Event 5 Investigation.

159. The Relationship Between Hospital Workload and Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-09/weissman-rothschild-report.pdf
     January 01, 2024 - identification and incorporated rule sets with criteria to define adverse event. … an accompanied access database to collect and compare the adverse event ratings. … Using random samples of event case summaries, our IRR for event classification (kappa = .69), event … The occurrence of an adverse medical event consistent with this medication. c. … Demonstration of the Computerized Adverse Event Detection Tool (CADET).

160. Slide 1 (ppt file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/simulation/simslides-update-62819.ppt
     January 30, 2006 - TEAMSTEPPS 05.2 Mod 1 05.2 Page * Page * Simulation Objectives To know and be able to apply the Event … TEAMSTEPPS 05.2 Mod 1 05.2 Page * Page * Simulation Define Event Sets Event sets are the building … sets Provides more than one opportunity to demonstrate behaviors Creates reliability Each event set … should not include more than one trigger event Event sets can be created by breaking a clinical procedure … Don’t ask too much; you won’t like what you get Rule of thumb: Have a key event every 1 to 2 minutes