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Total Results: 5,333 records

Showing results for "event".

161. Learn from Defects Tool | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/toolkit/learn-defects.html
     December 01, 2012 - A defect is any clinical or operational event or situation that you would not want to have happen again … For this investigation, put yourself in the place of those involved and in the middle of the event as … Try to view the world as they did when the event occurred. Why did it happen? … Did the provider's outlook or perception of his or her own professional role affect this event? … Review the list of contributing factors above and identify the most important ones related to this event

162. Final progress Report: Anticholinergics and Cognitive Decline in the Elderly with Depression (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/aparasu-report.pdf
     January 01, 2024 - date Cases Controls Controls chosen at event date Event date for cases Anticholinergic use … were captured 30 days before the event date using Medicare Part D data. … days before the event date using Medicare Part D data. … As before, the earlier date of occurrence was considered the event date. … A fall is a major event in the life of an older person.

163. Blood Dashboard Data (xls file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/Blood_Dashboard_Data_2019.xlsx
     January 01, 2019 - Type of Blood Product by Extent of Harm Blood_3 Stage of the Process When Blood or Blood Product Event … Originated Blood_4 Stage of the Process When Blood or Blood Product Event Originated by Extent … Blood_4 Blood_4: Stage of the Process When Blood or Blood Product Event Originated Process When Blood … or Blood Product Event Originated Percentage Frequency Post-transfusion or administration 18.8% 440 … Blood_5 Blood_5: Stage of the Process When Blood or Blood Product Event Originated by Extent of Harm

164. Medication or Other Substance Dashboard (xls file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/Medication_Dashboard_Data_2019.xlsx
     January 01, 2019 - 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 Administering 31.7% 10,525 … Monitoring 3.4% 1,118 Storing 2.3% 775 Unknown 1.2% 412 Purchasing 0.3% 87 Med_7 Med_7: Stage Event … Originated by Extent of Harm Stage Event Originated No Harm Percentage No Harm Frequency Harm Percentage

165. Sample Disaster Preparedness Letter to Families (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/nursing-home/resources/letter-emergency-contact.docx
     May 12, 2022 - health, safety, and dignity of your loved one and are committed to protecting our residents in the event … we can contact during an emergency to share our plans for sheltering in place or evacuation in the event … We would discuss this option further with you while we prepare for such an event. … Please complete the information below for our records so we know how best to proceed in the event of

166. Final Progress Report: Ambulatory Patient Safety of Clients in Treatment for Substance Abuse (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/mcfarland-report.pdf
     January 01, 2025 - Event Reporting Requirements* No Yes n % n % Required to report serious event 8 42 11 58 Required … Self-Disclosing a Serious Event If you committed an error resulting in serious event for the client … (circle all that apply) Near Miss  Minor, temporary event  Minor, permanent event Major, temporary  … event  Major, permanent event  Serious event I don’t know 8. … (circle all that apply) Event entered into an in‐house database   Investigated event on your own   

167. Implementation Guide for the CANDOR Process: Appendix B | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/capacity/candor/impguide/apb.html
     February 01, 2017 - 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

168. Hospital Survey on Patient Safety (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.doc
     June 09, 2016 - Instructions This survey asks for your opinions about patient safety issues, medical error, and event … · An “event” is defined as any type of error, mistake, incident, accident, or deviation, regardless … When an event is reported, it feels like the person is being written up, not the problem (1 (2 (3 … 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

169. Event Investigation and Analysis Guide: Appendix B | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/capacity/candor/modules/guide4/apb.html
     February 01, 2017 - Event Investigation and Analysis Guide: Appendix B Event Type: Individuals Interviewed … Timeline of Event: March 12, 2014 (0900) RN#1 received report from ED on patient Mrs.

170. Hospital Survey on Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.pdf
     December 22, 2017 - • An “event” is defined as any type of error, mistake, incident, accident, or deviation, regardless … When an event is reported, it feels like the person is being written up, not the problem ......... … We are given feedback about changes put into place based on event reports ......................... … 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

171. Hospital Survey on Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/resources/hospscanform.pdf
     March 22, 2017 - • An “event” is defined as any type of error, mistake, incident, accident, or deviation, regardless … When an event is reported, it feels like the person is being written up, not the problem ......... … We are given feedback about changes put into place based on event reports ......................... … 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

172. Final Progress Report: Mining complex clinical data for patient safety research (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/hripcsak-report.pdf
     January 01, 2024 - Incidence for most individual event types was 1% or less per admission or visit. … Methods Overview of event detection We developed a framework for automated event discovery from the … For each event type, a query was performed based on the include/exclude criteria. … We studied event monitors, which can be used to deploy event detection logic in real time [9]. … Policy and the Future of Adverse Event Detection Using Information Technology.

173. Chapter 4. Results and Key Findings | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/chapter4.html
     August 01, 2022 - What caused the patient safety event to happen? Where did the patient safety event happen? … What impact did the patient safety event have? … What were the consequences of the patient safety event? … to the event; whether or to whom an event was reported; what happened when an event was reported; and … the impacts or consequences of the event.

174. AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Sensemaking and Learn from Defects
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/sensemaking.pptx
     May 01, 2017 - from Defects Sensemaking Overview4 A conversation among members of an organization involved in an event … /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 … from Defects 13 Learning From Defects Overview Health care providers are adept at reacting to an event … The attributes of medical event-reporting systems: Experience with a prototype medical event-reporting

175. Identify Defects Through Sensemaking | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/modules/identify/identify.html
     December 01, 2012 - The purpose is to reduce the ambiguity about the event/issue—literally to make sense of it. … Each person brings his or her experience of that event/issue to the discussion. … Antecedent Event Root Causes Root Cause Classification Codes Recovery Return to Contents … 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

176. Executive Summary | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/summary.html
     August 01, 2022 - The TEP includes experts in patient safety, patient safety event reporting systems, health care delivery … care experience with patient safety events that may be useful and/or actionable in a patient safety event … What is the most effective operational approach for consumers to report patient safety event information … to the event; whether or to whom an event was reported; what happened when an event was reported; and … the impacts or consequences of the event.

177. Implementation of an Event Reporting and Learning System Leads to Improvements in Patient Safety Culture at UNC Medical Center - Intro (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/1-unc-webcast-intro.pdf
     December 18, 2019 - Implementation of an Event Reporting and Learning System Leads to Improvements in Patient Safety Culture … at UNC Medical Center - Intro Implementation of an Event Reporting and Learning System Leads to Improvements

178. Patient Safety Learning Pilot: Narratives from the Frontlines (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Kellie_30.pdf
     April 21, 2008 - Initially, errors are detected by hospital staff who complete Event Registration and Event Discovery … via an email containing a link to the event. … to the prior event, and the causal codes are shared. … and how we pay attention to the reasons for such an event. … the collective understanding of the event

179. Blood Dashboard Data (xls file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/Blood_Dashboard_Data_2024.xlsx
     January 01, 2024 - Type of Blood Product by Extent of Harm Blood_2 Stage of the Process When Blood or Blood Product Event … Originated Blood_3 Stage of the Process When Blood or Blood Product Event Originated by Extent … Blood_3 Blood_4: Stage of the Process When Blood or Blood Product Event Originated Process When Blood … Blood_4 Blood_5: Stage of the Process When Blood or Blood Product Event Originated by Extent of Harm … Stage of Process When Blood or Blood Product Event Originated No Harm Percentage No Harm Frequency

180. Generic Dashboard Data 2024 (xls file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/Generic_Dashboard_Data_2024.xlsx
     January 01, 2024 - of Event/Unsafe Condition by Event Type Gen_3 Location of Event/Unsafe Condition by Report Type … _6 Near Miss Prevention Actions within Event Types Gen_7 Extent of Harm by Event Type, Age, and … Gen_3 Location of Event/Unsafe Condition by Event Type Event Type Location of event/unsafe condition … Gen_5 Contributing Factors by Event Type Event Type Contributing Factor(s) for Event Event Frequency … Gen_7 Near Miss Prevention Actions within Event Types Event Type Near Miss Prevention Action Event