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www.ahrq.gov/research/findings/final-reports/stpra/stpra2.html
April 01, 2018 - probabilities of event combinations. … Event 660 Patient fails to notice infection during home care. … Event 642 Staff fail to protect patient effectively. … Event 450 Obese, but not diabetic, patient (30 ≤BMI <40). … Event 182 Fail to administer indicated antibiotics.
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www.ahrq.gov/sites/default/files/wysiwyg/topics/development-and-usability-testing-common-formats.pdf
January 01, 2022 - Agency for Healthcare Research and Quality (AHRQ) began the de-
velopment of the Common Formats for Event … Results: Estimated completion time was 30 to 90 minutes per event. … The CFER-DS also
offers a definition of a diagnostic safety event using concepts pro-
posed in 2 prior … Participants were asked to complete
the CFER-DS to simulate event reporting for 5 cases of diagnostic … DISCUSSION
Standards for diagnostic safety event reporting are necessary to
advance national-level
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www.ahrq.gov/sites/default/files/wysiwyg/npsd/Blood_Dashboard_Data_2021.xlsx
January 01, 2021 - 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 Event … Blood_5
Blood_5: Stage of the Process When Blood or Blood Product Event Originated
by Extent of Harm … Process When Blood or Blood Product Event Originated No Harm Percentage No Harm Frequency Harm Percentage
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www.ahrq.gov/sites/default/files/wysiwyg/npsd/Blood_Dashboard_Data_2023.xlsx
January 01, 2023 - 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 … or Blood Product Event Originated Percentage Frequency Total
Post-transfusion or administration 13.3% … 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
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www.ahrq.gov/policymakers/psoact.html
October 01, 2014 - deliberations, resulting in under-reporting of events and an inability to aggregate sufficient patient safety event … By analyzing patient safety event information, PSOs will be able to identify patterns of failures and … Many providers fear that patient safety event reports could be used against them in medical malpractice … patient safety work product" and "patient safety evaluation systems," which focus on how patient safety event
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Shah_99.pdf
March 23, 2008 - Quality of care standards
are especially salient when a trainee is faced with a patient adverse event … Yet, in adverse event
situations in which care standards do not exist, rules with which to proceed are … Statements addressing a negligence-based event made up less than half the responses (11/28). … How many times have you not told a patient about an adverse
event that affected them?
5. … Our study specifically studied the term “adverse
event.”
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www.ahrq.gov/patient-safety/reports/hotline/conclusios6.html
May 01, 2016 - that had little overlap with the information received from other sources (such as internal adverse event … Those projects have included sponsoring user-driven research to improve measurement and event reporting … When adverse event reporting systems were first built, they did not receive many reports. … It was not until the culture in hospitals changed around adverse event reporting that reports started … Safety Improvements Within Health Systems
Use of Patient Event Reporting for Public Information and
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www.ahrq.gov/hai/cusp/modules/patient-family-engagement/alt-text-tab.html
September 01, 2013 - improve communication among patients, families, and clinicians
Discuss how to communicate an adverse event … improve communication among patients, families, and clinicians
Discuss how to communicate an adverse event …
Slide 22
Introduction to Adverse Events
Adverse event: An injury to a patient … is essential
Slide 23
Immediate Response to an Adverse Event 3
Care for the … in the medical record
Slide 24
Next Steps in Responding to an Adverse Event 5
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/scenarios.html
August 01, 2022 - Contents
Scenario 1: Non-Clinical Situation, Group Project
Scenario 2: Disclosure Immediately After Event … Scenario 3: Disclosure After Event Analysis
Scenario 4: Disclosure After Event Analysis … Return to Contents
Scenario 2: Disclosure Immediately After Event
Mary is a 39-year-old … Return to Contents
Scenario 3: Disclosure After Event Analysis
Adam, a 55 year-old … Return to Contents
Scenario 4: Disclosure After Event Analysis
Alphonse, a 50 year-old
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Kizer2.pdf
December 01, 2000 - Event Additional specifications
3. Patient protection events
A. … Event Additional specifications
5. Environmental events
A. … Event means a discrete, auditable, and clearly defined occurrence. … , an event whose occurrence is not trivial. … the additional information as a separate event.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Nosek.pdf
March 01, 2004 - Standardizing Medication Error Event Reporting in the U.S. … Department of Defense
361
Standardizing Medication Error Event
Reporting in the U.S. … A primary goal was the creation of
a standardized medication event reporting system, including a central … This index scale ranges in event
severity from Category A (a potential error), through Category I (a … A centralized medical event data registry
incorporating the use of MEDMARX was established at the DoD
-
www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/quality-measures/qsrs/qsrs-2021-2022-adverse-event-data-report.pdf
January 01, 2022 - Trends in adverse event rates in hospitalized patients, 2010-2019. … Medication Anticoagulant event – Intravenous unfractionated
heparin event
20
Module Adverse … Event (AE) Outcome
Anticoagulant event – Warfarin event
Anticoagulant event – Low molecular weight … Medication Other medication event identified by abstractor
7. … Determining Adverse Event Rates
D. Weighting Methodology
IV.
-
www.ahrq.gov/teamstepps/simulation/traininggd.html
July 01, 2016 - The Simulation Module for Assessment of Resident Targeted Event Responses (SMARTER) approach is an event-based … All event sets consist of a trigger—the condition under which the event becomes fully activated or the … Each event set should include only one trigger event to avoid introducing too many variables and making … Explain that each slide can be chunked into two event sets, with one trigger for each event set. … Event set with trigger and distracters.
-
www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/quality-measures/qsrs/qsrs-2021-2022-adverse-event-data-report-oct-rev.pdf
January 01, 2022 - Trends in adverse event rates in hospitalized patients, 2010-2019. … Medication Anticoagulant event – Intravenous unfractionated
heparin event
20
Module Adverse … Event (AE) Outcome
Anticoagulant event – Warfarin event
Anticoagulant event – Low molecular weight … Medication Other medication event identified by abstractor
7. … Determining Adverse Event Rates
D. Weighting Methodology
IV.
-
www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/quality-measures/qsrs/qsrs-2021-2022-adverse-event-data-report-nov-rev.pdf
January 01, 2022 - Trends in adverse event rates in hospitalized patients, 2010-2019. … Medication Anticoagulant event – Intravenous unfractionated
heparin event
20
Module Adverse … Event (AE) Outcome
Anticoagulant event – Warfarin event
Anticoagulant event – Low molecular weight … Medication Other medication event identified by abstractor
7. … Determining Adverse Event Rates
D. Weighting Methodology
IV.
-
www.ahrq.gov/news/meps-webinars.html
May 01, 2024 - the example exercise about how to link the medical conditions public use data file to other medical event … the example exercise about how to link the medical conditions public use data file to other medical event
-
www.ahrq.gov/sites/default/files/wysiwyg/npsd/Blood_Dashboard_Data_2022.xlsx
January 01, 2022 - 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 Total
Post-transfusion or administration 13.6% … Blood_5
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
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/162-example-completed-learning-defects-tool.docx
October 01, 2024 - A defect is any clinical or operational event that you would not want to happen again. … In the space below, identify the MRSA infection or other event. … Please describe the event to include the timeline, witnesses, and decisions that were made. … Try to view the world as they did when the event occurred. … Event Components
Descriptions
Event
Patient A developed a hospital-acquired central line-associated
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www.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/user-guide-covid-19-vaccination-tracking-tool-nursing-facilities.pdf
July 01, 2022 - Select Adverse Event (Reaction) to 1st Dose. … Select Adverse Event (Reaction) to 2nd Dose. … Adverse Event (Reaction) to any COVID-19 Vaccine Dose? … Select Adverse Event (Reaction) to 1st Dose. … Select Adverse Event (Reaction) to 2nd Dose.
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/patientsafety/qdr2016-ptschartbook.pdf
July 19, 2017 - The chart shows the
distribution of reports by event type. … Patient Safety Event Reports, by Event Type and Harm
0
5,000
10,000
15,000
20,000
25,000
Unsafe … Conditions
Near-Miss Patient Event,
No Harm
Patient Event,
Harm
N
u
m
b
e
r
o
f
Ev
e
n
ts … a variety of event-related
metrics (e.g., event types, harm, top drug classes involved) for each member … It reflects the ratio of patient
safety event reports with high harm to all event reports where the