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www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/leveraging-data-slides.pdf
April 01, 2021 - information and
links to COVID-19 resources
(https://takeheart.ahrq.gov/coronavirus)
Today’s Event … TAKEheart participants should submit a completed plan by Dec.
18
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
Please
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/pf-engagement-facilitator-guide.pdf
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.
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www.ahrq.gov/news/events/nac/2023-03-nac/agenda-071223.html
June 01, 2023 - Closed captioning will be provided during this event . … Time
Event
11:15 a.m. – 11:30 a.m.
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www.ahrq.gov/news/events/nac/2022-05-nac/agenda-051222.html
May 01, 2022 - Closed captioning will be provided during this event . … Time
Event
10:00 a.m. – 10:15 a.m.
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www.ahrq.gov/patient-safety/reports/hotline/summary.html
May 01, 2016 - designed and assembled the key building blocks of the hotline prototype, including a patient-oriented event … and the AHRQ Common Formats, a which includes definitions of adverse events and forms for adverse event … These systems were then analyzed by event type, reporting mode, key terms used, and other criteria. … In response to feedback from the TEP, the researchers revised the patient event reporting form and other … Because of OMB requirements, only minor adjustments to the patient event reporting form and Web content
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/hospwebinar/just-culture-webcast-1-intro.pdf
November 09, 2016 - Frequency of event reporting
– 4. Handoffs & transitions
– 5. … Defining Nonpunitive Response to Error
11
The extent to which staff feel
that their mistakes and event … Response to Error Survey
Items
– Staff feel like their mistakes are held against them.
– When an event
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www.ahrq.gov/cpi/about/otherwebsites/qsrs.ahrq.gov/index.html
March 01, 2021 - Features
The QSRS:
Offers an expanded array of adverse event measures. … standardized definitions and algorithms, consistent with those used by the AHRQ Common Formats for Event
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide6.html
August 01, 2022 - that these tiers of support are provided to caregivers after they have in been involved in an adverse event … YES NO
Adverse Event Investigation Process
Is an adverse event policy in place … Do you have an event investigation process clearly outlined? … available interventional support strategies for clinicians in the aftermath of an unanticipated clinical event … Providing supportive care following an unanticipated clinical event.
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www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module4/mod4-slides.html
March 01, 2017 - When an adverse event occurs, it can be difficult for a care provider to take ownership and communicate … Prompt, compassionate, and honest communication with the resident and family after an adverse event is … Next Steps in Responding to an Adverse Event
Care for the resident. … Document the event and follow all related facility policy.
Investigation. … Slide 30: How To Communicate About An Adverse Event
Speak slowly and use clear language.
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www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/practical-methods-care-coordination-slides.pdf
December 14, 2022 - the chat box, please list any questions
or comments you have for the panelists.
13
Next Steps
Event … interest, and any resources or
strategies you’re using that are working well
Feedback on Today’s Event … : Please respond to the polling questions
before you exit today’s event
14
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit5-10.html
November 01, 2014 - Lesson learned: Documents insights and lessons learned from the event. … Report-out: Reports results from the event and any future process changes to be implemented as part of … Implementation: Implements the project widely within the department during the first 2 weeks after the event
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/20140115_DB/1_Dale_Shaller_Intro_slides_1-11.pdf
January 15, 2014 - Download slides from the
console.
8
Accessing Event Materials
To access the event materials … To Ask a Question
Accessing Presentations
Accessing Event Materials
Part I: CAHPS Database Overview
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes8.html
August 01, 2022 - After the resolution of a CANDOR event, information is fed into an organization’s performance improvement … These may include a checklist to follow after an event. … Event Reporting, Investigation, and Analysis Team.
Resolution Team. … Ask patients and family members to share their stories to put a human face on a harm event and engage … Think about a patient story involving a CANDOR 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/vol3/Advances-Riley_58.pdf
April 02, 2008 - validated event
sets. … • “2” Behavior occurred more than 90 percent of the times when prompted by the event set. … The performance of these teams throughout the critical event was sporadic and uneven. … Unlike conventional teams, critical event team membership is not constant. … Sentinel Event Alert; Issue 30. Oakbrook Terrace, IL:
The Joint Commission; 2004 July 21.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cusp-icu-slides.pptx
April 01, 2022 - Program for ICUs: Preventing CLABSI and CAUTI
Applying CUSP ׀ 10
10
Where To Find Defects8,9
Adverse event … Analysis
To identify root causes of an infection, opportunities for improvement
Tools/techniques
CLABSI Event … Report template
CAUTI Event Report template
5 Whys
Staff Safety Assessment
Brainstorming
To generate … Event Report Tools
The event report tools have the following domains:
Demographics
CLABSI/CAUTI information … ICU
Video – Creating Team Buy-In To Work Toward Zero Preventable Infections in ICUs
CLABSI and CAUTI Event
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www.ahrq.gov/teamstepps-program/curriculum/team/tools/debrief.html
December 01, 2023 - Analysis of why the event occurred, what worked, and what did not work. … Debriefs can be a short (about 3 minutes or less) team event, typically initiated and facilitated by
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www.ahrq.gov/sites/default/files/2024-01/anumba-report_0.pdf
January 01, 2024 - The case would be filed as a Healthcare-Associated Infection (HAI) event. … HAI Event Other Event
Figure 1: Data Model Framework
The data model is set up with four main classes … Only sub-classes of Fall Events, HAI Event, and Other Event are included,
because they are the only … Any one Patient Safety Event
can be related to one or more health threats. … date of the event, and the end time.
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www.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/vaccination-tracking-tool-userguide.pdf
May 01, 2021 - It is important
to associate lot # with any adverse event or a manufacturer recall (Figure 4). … Select Adverse Event Reaction to 1st Dose. … Select Adverse Event Reaction to 2nd Dose. … Select Adverse Event Reaction to 1st Dose. … Select Adverse Event Reaction to 2nd Dose In the cell under the Adverse Event (Reaction) to
2nd Dose
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_4-situation-monitoring-speaker-notes.pdf
July 01, 2023 - • What system issues contributed to our handling of the event? … • What teamwork behaviors contributed to our handling of the event? … • What system issues contributed to our handling of the event? … • What teamwork behaviors contributed to our handling of the event? … Please note that the scenario does not
relate to a severe hypertension event.
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www.ahrq.gov/sites/default/files/2024-01/fernandez-rosenman-report.pdf
January 01, 2024 - (s)
Define (Event)
Triggers
Identify observable, clinically
appropriate triggers for each
event … event. … metric that were confusing, poorly defined, or assigned to an
inappropriate event. … Event-based approach to measurement (EBAM)
6. … Event-based approach to training (EBAT). Int. J. Aviat. Psychol.
1998;8(3):209-221.
37.