-
www.ahrq.gov/sites/default/files/publications/files/11-0060-EF.pdf
May 01, 2011 - to the event; whether or to whom an event was reported; what
happened when an event was reported; and … What caused the patient safety event to happen?
Where did the patient safety event happen? … report the event. … to the event; whether or
to whom an event was reported; what happened when an event was reported; and … These prompts
will be designed to capture the type of event (e.g., harm event, no harm event, close
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/consumer-experience/reporting/11-0060-EF.pdf
May 01, 2011 - to the event; whether or to whom an event was reported; what
happened when an event was reported; and … What caused the patient safety event to happen?
Where did the patient safety event happen? … report the event. … to the event; whether or
to whom an event was reported; what happened when an event was reported; and … These prompts
will be designed to capture the type of event (e.g., harm event, no harm event, close
-
www.ahrq.gov/patient-safety/resources/consumer-exp/reporting/chapter4.html
October 01, 2014 - 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.
-
www.ahrq.gov/news/newsroom/case-studies/ktcp316.html
October 01, 2014 - in time to incorporate it into an October 2008 drill that simulated a regional large-scale explosive event … the Incident Command Module prompted important time parameters, such as beginning and ending of the event … The staff found that with the tool, the post-event documentation was easy and efficient. … the National Foundation for Trauma Care as one of the five "Highly Prepared Trauma Centers" in the event … of a natural or human-caused event of mass scale in the nation.
-
www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-case2.html
November 01, 2014 - Each process or event on the value stream became a Lean event, with one Lean event scheduled per month … The team leader assists the event week team in meeting its objective by organizing pre-event preparation … After the RCI Event
Changes are implemented the Monday following the event and sometimes sooner. … The team leader for this event led the RCI event team but did not participate in pre-event or post-event … Planning and Implementation
The RCI event on surgical procedure cards was the ninth event of the surgical
-
www.ahrq.gov/sites/default/files/wysiwyg/npsd/Data_Submission_Dashboard_Data_2019.xlsx
January 01, 2019 - tables include distributions of events and unsafe conditions reported by PSOs using Common Formats for Event … Common Formats Version DS_3
Percentage of Total Reports by Report Type DS_4
Percentage of Event … Incident 75.5% 860,043
Near Miss 19.0% 216,549
Unsafe Condition 5.5% 62,532
DS_5
DS_5: Percentage of Event … Type by Common Formats Version
Event Type Version Frequency Percentage
Other CFER-H V1.1 153,170 56.1%
-
www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/affinity-group-innovations-improve-cr.pdf
February 13, 2023 - Register for the event:
https://abtassociates.webex.com/abtassociates/onstage/g.php? … /takeheart.ahrq.gov/join-takeheart
2
Today’s Event … Remember to click SUBMIT when complete
13
Resources Mentioned in Today’s Event … discussions of key topics with peers at:
https://takeheart.ahrq.gov/collaboration
Today’s slides and an event … summary will be emailed to event
participants and posted online at: https://takeheart.ahrq.gov
-
www.ahrq.gov/sites/default/files/wysiwyg/npsd/Data_Submission_Dashboard_Data_2024.xlsx
January 01, 2024 - tables include distributions of events and unsafe conditions reported by PSOs using Common Formats for Event … Common Formats Version DS_3
Percentage of Total Reports by Report Type DS_4
Percentage of Event … DS_5
DS_5: Percentage of Event Type by Common Formats Version
Event Type Version Frequency Percentage
-
www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/21264-Aparasu-draft-1.pdf
July 31, 2018 - 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.
-
www.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/apc.html
August 01, 2022 - Does the hospital routinely use its patient REAL data to identify patient safety event disparities and … Is an attempt made to disclose within the first 24 hours following an adverse event?
… Do staff have the opportunity to participate in event investigations and process improvement initiatives … Has an organized process to assess behavior related to the event been established?
… Is supportive care provided to the caregiver within 24 hours of the event?
-
www.ahrq.gov/sops/events/webinars/just-culture/introduction.html
January 01, 2017 - Accessing Resources
Webinar console with arrows showing how to access additional event materials and … Frequency of event reporting.
Handoffs & transitions.
Management support for patient safety. … index.html
Defining Nonpunitive Response to Error
The extent to which staff feel that their mistakes and event … When an event is reported, it feels like the person is being written up, not the problem.
-
www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/hospital/hospwebinar/just-culture-intro.html
January 01, 2017 - Accessing Resources
Webinar console with arrows showing how to access additional event materials and … Frequency of event reporting.
Handoffs & transitions.
Management support for patient safety. … hosp-reports.html
Defining Nonpunitive Response to Error
The extent to which staff feel that their mistakes and event … When an event is reported, it feels like the person is being written up, not the problem.
-
www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/affinity-details-emerging-strategies-cr.pdf
January 01, 2021 - EVENT SUMMARY
LEARNING COMMUNITY AFFINITY GROUP | SUMMARY AT-AT-GLANCE | 1
AFFINITY GROUP DETAILS … Format • A moderated panel discussion with five panelists, with additional input
from the 129 event … Greater Lansing Cardiac Rehabilitation,
Lansing, MI
Resource Link Slides and a recording of the event … OF CR PROGRAM OPERATION
STATUS AT-A-GLANCE
Current State Future State
Participants in this event … Reasonably normal operations
EVENT SUMMARY
LEARNING COMMUNITY AFFINITY GROUP | SUMMARY
-
www.ahrq.gov/news/newsroom/case-studies/cquips0703.html
October 01, 2014 - Web-based initiative to assess staff attitudes and beliefs about patient safety, medical errors, and event … questions asked staff to "grade" their work area as it related to patient safety and the number of event … Secondly, the Patient Safety Reporting System will provide standardized event and near-miss capturing
-
www.ahrq.gov/downloads/pub/advances/vol2/Hunt.pdf
July 01, 2004 - Exposure/adverse event (the name of the exposure/adverse event).
2. … Description (a description of the exposure/adverse event measure).
3. … The adverse event occurrence or the
occurrence, of an event considered as a proxy for an adverse event … • the adverse event is common. … • the adverse event is preventable or repairable.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Hunt.pdf
July 01, 2004 - Exposure/adverse event (the name of the exposure/adverse event).
2. … Description (a description of the exposure/adverse event measure).
3. … The adverse event occurrence or the
occurrence, of an event considered as a proxy for an adverse event … • the adverse event is common. … • the adverse event is preventable or repairable.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module3/module3-assessment-change-readiness-gap-analysis.pptx
August 25, 2015 - Define a CANDOR event.
Develop a measurement strategy.
Communicate for understanding and buy-in. … Define a CANDOR event.
Develop a measurement strategy.
Communicate for understanding and buy-in. … Event Reporting, Investigation, and Analysis Team—responsible for reviewing the organization’s current … Strategy
Define a CANDOR event.
Develop a measurement strategy. … and Event Investigation and Analysis.
15
References
Kotter J.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Pronovost_95.pdf
June 12, 2008 - An event that causes harm is typically
called an adverse event (e.g., retained surgical instrument); … at risk of the event). … That is, the odds that an event will result in harm. … The
attributes of medical event reporting systems:
Experience with a prototype medical event reporting … Sentinel
event alert. Issue 11, November 19, 1999.
-
www.ahrq.gov/sops/international/hospital/translators.html
October 01, 2014 - Hospital management seems interested in patient safety only after an adverse event happens. … When an event is reported, it feels like the person is being written up, not the problem. … The term "rating" can be used instead of "grade." )
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 … In the past 12 months, how many event reports have you filled out and submitted?
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/resources/infotranshsops.pdf
September 01, 2009 - 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. … When an event is reported, it feels like the person is being written up, not the problem. … 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.