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  1. www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-patterns-fall-interventions.pdf
    September 01, 2023 - Healthcare providers submit patient safety event data to Patient Safety Organizations (PSOs), which … As of December 31, 2022, the PSOPPC has maintained over 2.6 million patient safety event reportsiii … In addition, causal inferences cannot be based on these event data alone. … associations between various concurrent reported event characteristics. … Does error and adverse event reporting by physicians and nurses differ? Jt. Comm. J. Qual.
  2. www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/best-practices/asp-pneumonitis-one-page.pdf
    November 01, 2019 - regimens for community-acquired pneumonia (CAP) (e.g., ampicillin- sulbactam, ceftriaxone) if the event … with regimens for hospital-acquired pneumonia (HAP) (e.g., cefepime, piperacillin- tazobactam) if the event … A proportion of patients (20–25%) may develop bacterial pneumonia 48–72 hours after an aspiration event
  3. www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/hospital/hospwebinar/just-culture-presentation.html
    January 01, 2017 - The Collaborative Prework RCA Event documentation. Employee Corrective Action Reports. … Policies; Corrective Action, Sentinel Events, Adverse Event Reporting. Patient Safety Plan. … When a patient safety event happens, hospital management looks at more than staff actions to determine … what led to the event.
  4. www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/Nursing-Home-Workplace-Safety-Resource-List.pdf
    January 01, 2023 - /resources/patient-safety-topics/sentinel-event/sentinel- event-alert-newsletters/sentinel-event-alert … /sentinel-event-alert-newsletters/sentinel-event-alert-59-physical-and-verbal-violence-against-health-care-workers … https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/sentinel- event-alert-newsletters … /sentinel-event-alert-60-developing-a-reporting-culture-learning-from- close-calls-and-hazardous-condi … /sentinel-event-alert-newsletters/sentinel-event-alert-60-developing-a-reporting-culture-learning-from-close-calls-and-hazardous-condi
  5. www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursing-home-workplace-safety-resources.pdf
    January 01, 2023 - /resources/patient-safety-topics/sentinel-event/sentinel- event-alert-newsletters/sentinel-event-alert … /sentinel-event-alert-newsletters/sentinel-event-alert-59-physical-and-verbal-violence-against-health-care-workers … https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/sentinel- event-alert-newsletters … /sentinel-event-alert-60-developing-a-reporting-culture-learning-from- close-calls-and-hazardous-condi … /sentinel-event-alert-newsletters/sentinel-event-alert-60-developing-a-reporting-culture-learning-from-close-calls-and-hazardous-condi
  6. www.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/exh2.html
    August 01, 2022 - A consumer interacts with health care facilities and providers and experiences an event. … Health care facilities and providers also add information about the event to reporting system records
  7. www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/best-practices/respiratory-facilitator-guide.pdf
    November 01, 2019 - Slide 23 Moment 1: Aspiration Event SAY: Pneumonitis is an abrupt chemical injury caused by … It progresses quickly to respiratory failure followed by rapid improvement within 48 hours of the event … Moment 1: Distinguishing Aspiration Events From Aspiration Pneumonia SAY: If an aspiration event … progresses to aspiration pneumonia, this generally occurs around 48 hours after the aspiration event … Treat as healthcare-associated pneumonia if the event occurred 72 hours or more after admission to a
  8. www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/01-sops-riverside-handoffs-webcast-intro.pdf
    October 30, 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
  9. www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/patfamilyengagement/CUSP-Patient-Family-Engagement.pptx
    May 01, 2013 - improve communication among patients, families, and clinicians Discuss how to communicate an adverse event … — Infrastructure advisory Engaging in everyday care — How-to strategies Engaging after an adverse event … Introduction to Adverse Events Adverse event: An injury to a patient caused by medical intervention … family Prompt, compassionate, and honest communication with the patient and family after an adverse event … the appropriate parties Communicate with the patient (who, what, when, where, and why) Document the event
  10. www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-143-section-5a-evidence-table.pdf
    January 01, 2014 - GJ, Study monitoring system that identified “alerts” that possibly indicated an adverse drug event … Adverse Drug Event Detection in Pediatric Oncology and Hematology Patients: Using Medication … Recognizing hypoglycemia in children through automated adverse-event detection. … Automated adverse event detection collaborative: electronic adverse event identification, classification … those with no event (95% CI 1.19 to 1.26).
  11. www.ahrq.gov/sites/default/files/2024-11/ridley-report.pdf
    January 01, 2024 - never event. … to the 2002 NQF Reportable Event Standard (N=188) NQF Event Standard (27) % 1. … Environmental events 26. 6 NQF Event Standard (27) % A. … They were also asked to determine the severity of the event, determine the preventability of the event … Regardless of type of event, the chart and the patient survey agreed 77% of the time that an event occurred
  12. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/pf-engagement-facilitator-guide.docx
    May 01, 2017 - Discuss how to communicate an adverse event to patients and family members. … Immediately after an adverse event, care providers: Provide care. … Caring for the patient’s physical needs after an event is the first step a provider must take. … event, and the care provided as a result of the event. … Rarely does an adverse event occur as a result of intent.
  13. www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/1-mo-webcast-2023-intro.pdf
    January 01, 2023 - Webcast Technical Info • Audio issues • Poor Connection • Use Q&A: For Questions or Other Problems • Event … events.westat.com/sops ► Download presentation slides and view the agenda and speaker bios on our event
  14. www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/primer-intro-2023.pdf
    January 01, 2023 - Webcast Technical Info • Audio issues • Poor Connection • Use Q&A: For Questions or Other Problems • Event … /events.westat.com/cahps/ ► Download presentation slides; view the agenda and speaker bios on our event
  15. www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/coping-staff-challenges-slides.pdf
    February 13, 2023 - information and links to COVID-19 resources (https://takeheart.ahrq.gov/coronavirus) 2 Today’s Event … 14 Resources Mentioned in Today’s Event  Dr. … 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  Please
  16. www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-falls-rev.pdf
    March 01, 2023 - Secondly, patient safety event reports are submitted by providers to PSOs, then by PSOs to the PSO … ii The initial report date represents the date a provider completed the Healthcare Event Reporting Form … It should be noted that a single event record may have more than one type of event specified. … as part of the voluntary event reporting to the NPSD (i.e., the total population at risk for a fall … However, standardization of event reports under the Common Formats does allow for valid comparisons
  17. Mod5-Case-Scenarios (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/mod5-case-scenarios.pdf
    April 01, 2016 - ........................................................2 Scenario 2: Disclosure Immediately After Event … ....................................................................3 Scenario 3: Disclosure After Event … ....................................................................4 Scenario 4: Disclosure After Event … Case Scenarios: Handling Challenging Communications – 3 Scenario 2: Disclosure Immediately After Event … Case Scenarios: Handling Challenging Communications – 5 Scenario 4: Disclosure After Event Analysis
  18. www.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/chapter6.html
    August 01, 2022 - instances in which consumers are likely to have more complete information regarding a patient safety event … Beyond positive impacts of this role for consumers, involvement of consumers in patient safety event … It will be important for members of the patient safety event reporting systems community to participate … Confidentiality of patient safety event reports, which may include protected health information (PHI) … To ensure appropriate confidentiality of patient safety event reports and thereby encourage consumers
  19. www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/1-sops101-webcast-2023-intro.pdf
    January 01, 2023 - Webcast Technical Info • Audio issues • Poor Connection • Use Q&A: For Questions or Other Problems • Event … events.westat.com/sops ► Download presentation slides and view the agenda and speaker bios on our event
  20. www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/01-sops-teamstepps-webcast-intro.pdf
    July 25, 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

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