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  1. www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit4-2.html
    November 01, 2014 - tone for Lean by participating in Lean events with staff and taking on action items developed at the event … Education and training : Self-study modules and training integrated into a Lean event can be effective … over-communicate process changes and the progress Lean teams make to staff that do not participate in a Lean event
  2. www.ahrq.gov/news/events/nac/2023-03-nac/agenda-030623.html
    February 01, 2023 - Closed captioning will be provided during this event . … Time Event 11:30 a.m. – 11:45 a.m.
  3. www.ahrq.gov/hai/tools/mvp/modules/technical/daily-early-mobility-slides.html
    February 01, 2017 - Event types. … Did the patient have an "event" while being mobilized within the last 24 hours? … Event codes are listed on the back of the data collection sheet. … Slide 30: Event Codes Image: Event codes for recording events that occur during mobilization. … Adverse event incidence rate (intubated and non-intubated).
  4. www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/anumba-report.pdf
    August 07, 2023 - 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.
  5. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/engagement.pptx
    May 01, 2017 - Patient & Family 5 Engagement Strategies Engaging in everyday care Engaging after an adverse event … Safety Program for Perinatal Care Patient & Family 16 Engaging After Adverse Events An adverse event … Prompt, compassionate, and honest communication with the patient and family after an adverse event is … the appropriate parties Communicate with the patient (who, what, when, where, and why) Document the event … in the medical record 18 AHRQ Safety Program for Perinatal Care Patient & Family Adverse Event
  6. www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/one-pager-aspiration-pneumonia.docx
    June 01, 2021 - is a bacterial pneumonia that may develop in some residents (20–25%) 48–72 hours after an aspiration event … Prevention—speech and swallow evaluation Antibiotics Respiratory support Treatment · Aspiration event … · Aspiration event and the resident becomes unstable · The following signs are indicative of unstable
  7. www.ahrq.gov/sops/international/hospital/translators-version-2.html
    October 01, 2024 - When an event is reported in this unit, it feels like the person is being written up, not the problem … (negatively worded) More about this item: When an event is reported, it feels like the person is … In this unit, we are informed about changes that are made based on event reports. … More about this item: When changes are made in response to patient safety event reports, staff are informed … Hospital management seems interested in patient safety only after an adverse event happens.
  8. www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/changes-slides.pptx
    November 01, 2019 - for Improving Antibiotic Use – Acute Care Learning From Antibiotic-Associated Adverse Events Adverse event … How will you reduce the risk of the adverse event from happening again? … Safety Program for Improving Antibiotic Use – Acute Care Responding to an Antibiotic-Associated Adverse Event … back to the group Determine if something can be measured to demonstrate that incidence of the adverse event … and proposed changes to reduce the likelihood of the adverse event happening again?
  9. www.ahrq.gov/patient-safety/reports/engage/appb.html
    March 01, 2017 - Harm Diagnostic error Defensive medicine Testing Leadership Safe care Sentinel event … Serious safety event High reliability Primary care General Internal Medicine
  10. www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/enhancing-care-heart-failure-patients.pdf
    February 13, 2023 - u n g , M S N , A N P - B C N o v e m b e r 2 , 2 0 2 1 Welcome and Background for Today’s Event … see your question Try the chat function now by sharing one thing you hope to learn during 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
  11. www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/situ/simulation-fac-guide.html
    July 01, 2023 - The participants are asked to treat the simulated event like an actual patient situation. … Event sets can be created by breaking a clinical situation into chunks. … For example, in a scenario, one event set may have to do with the identification of an issue needing … activation of a rapid response from clinical staff, another event set might have to do with selecting … Each event set usually has one trigger.
  12. www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-230-tech-specs.pdf
    July 12, 2019 - Event/Diagnosis An outpatient care visit. … height, weight percentile, or height percentile alone is not sufficient to qualify as a numerator event … height, weight percentile, or height percentile alone is not sufficient to qualify as a numerator event
  13. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Murff.pdf
    January 01, 2004 - The event undergoes an expedited review by the IRB committee chair, and no action is suggested. … Near-miss reporting systems have many potential benefits over adverse event detection systems. … “Near-miss” Reporting: Implications for Human Protection 189 Adverse event example. … to and management of the adverse event would have likely been less timely. … Web-based adverse event reporting will help notify the IRB of potential problems as they occur.
  14. www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/cholesterol-narrative.pdf
    December 31, 2018 - Registered Nurses (APRN) Ages 21 years and older as of January 1 of the measurement period Event … Patients who met any of the following criteria are identified as at high risk of a cardiovascular event … Measure Type Process Description Methodology Eligible Population Eligible Providers Ages Event
  15. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/vae/vae-tool.docx
    January 01, 2017 - Prevention Bundle AHRQ Safety Program for Mechanically Ventilated Patients Ventilator-Associated Event … Unit __________ Use this tool to track your progress in reducing ventilator-associated event
  16. www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/emerging-strategies-slides.pdf
    August 12, 2020 - takeheart.ahrq.gov/coronavirus) 2 Today’s Event … 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 
  17. www.ahrq.gov/patient-safety/reports/engage/appc.html
    March 01, 2017 - Patient Safety Net (PSNet): "medical errors"[MeSH Terms] OR "iatrogenic disease"[MAJR] OR "sentinel event … approach"[All Fields] OR "medical error*"[All Fields] OR "medical mistake*"[All Fields] OR "adverse event … iatrogenic disease [mh] OR sentinel surveillance [mh] OR safety [mh] OR (adverse [ti] AND (drug* [ti] OR event
  18. www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module4/mod4-facguide.html
    March 01, 2017 - The Debrief meeting is ideally conducted with all team members that were involved in the event. … Caring for the resident's physical needs after an event is the first step a provider must take. … However, prompt, compassionate, and honest communication following an event is essential. … , the resident's response to the event, and the care provided as a result of the event. … about an adverse event should be compassionate and sensitive.
  19. www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/22458-Rosenman-report.pdf
    October 01, 2018 - (s) Define (Event) Triggers Identify observable, clinically appropriate triggers for each eventevent. … 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.
  20. www.ahrq.gov/teamstepps/simulation/traininggd1.html
    July 01, 2016 - Because the checklists are event-based and the scenarios are scripted in advance, the rater knows when … each event will occur and can direct his or her attention to the targeted responses. … A good rule is that they have a key event every 1 to 2 minutes of scenario time. (2 min.) … Remind participants that event-based methods involve more than just measurement. … Event-based methods involve good training design practices, good scenario design practices, and good

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