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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
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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.
-
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.
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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.
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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/
-
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.
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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
-
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.
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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.
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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.
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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
-
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?
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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
-
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.
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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
-
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 .
-
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
-
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.
-
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).
-
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