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Showing results for "event".

41. Implementation of a Data-based Medical Event Reporting System in the U.S. Department of Defense (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Davis.pdf
    February 12, 2004 - a “sentinel event” was used. … was a near miss or an actual event. … Each actual event is categorized with a SAC score. … If there are no subcategories for an event, the number given to the event or the event description … is usually a condensed version of the event and gives no causal factors related to the event.

42. Module 1: An Overview of the CANDOR Process | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes1.html
    August 01, 2022 - A CANDOR event is an event that involves unexpected patient harm. … cause of a harm event. … the event. … Say: More information on Event Identification and Reporting of a CANDOR event will be discussed in … Resolution of the event can only occur after Event Investigation and Analysis has been completed.

43. What Happens After a Patient Safety Event? Medical Expenditures and Outcomes in Medicare (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Encinosa.pdf
    January 01, 2003 - What Happens After a Patient Safety Event? … Medical Expenditures and Outcomes in Medicare 423 What Happens After a Patient Safety Event? … PSI refers to a patient safety event occurring. … , with $288 in extra outpatient payments attributable to the event (P < 0.05). … PSI refers to a patient safety event occurring.

44. Module 5: Response and Disclosure | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/notes.html
    August 01, 2022 - and of the impact of the event on their care. … What are the implications of the event for the patient's health? Why did the event happen? … the system" for the event. … Can I see a copy of the event analysis? … It is rarely helpful to share all event analysis findings.

45. Chapter 3. Description of Methods | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/chapter3.html
    August 01, 2022 - , and communication or coordination issues that contributed to the event. … from the time the event occurred ("real time") to well after the event, once they have had time to heal … A total of 74 patient safety event reporting systems were identified. … had a family member who had experienced a patient safety event. … the event.

46. Network of Patient Safety Databases Chartbook, 2023 (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2023-rev.pdf
    January 01, 2023 - event types. … OF EVENT OR UNSAFE CONDITION by EVENT TYPE. … to the event?” … event? … (EVENT ID); and the REPORT TYPE, category of event (EVENT TYPE), and INITIAL REPORT DATE.

47. Blood and Blood Product Dashboard | Agency for Healthcare Research and Quality
    www.ahrq.gov/npsd/data/dashboard/blood.html
    September 01, 2024 - blood product involved, type of blood product by residual harm to the patient, stage of process where event … originated, and stage of process where event originated by residual harm to the patient.

48. An Overview of the CANDOR Process
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4/module4-event-reporting-investigation-analysis.pptx
    September 10, 2015 - Reporting, Event Investigation and Analysis Module 4 of the CANDOR Toolkit covers the Event Reporting … Identify the key components of an effective event analysis. 2 CANDOR Event Reporting, Investigation, … of the event are imperative.   … information on the event. … in event reporting, including; How the event was reported.

49. The PSO Privacy Protection Center | Agency for Healthcare Research and Quality
    www.ahrq.gov/cpi/about/otherwebsites/psoppc.ahrq.gov/index.html
    September 01, 2018 - The PSOPPC provides technical assistance to PSOs to ensure that patient safety event data is rendered … The Common Formats promote consistent event reporting by all providers and health care organizations … assistance services, such as— Educating PSOs on the format for submitting nonidentifiable patient safety event … Rendering PSO patient safety event data nonidentifiable. … software vendors interested in implementing common definitions and reporting formats for patient safety event

50. Physician Event Reporting: Training the Next Generation of Physicians (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Nguyen.pdf
    May 01, 2003 - Physician Event Reporting: Training the Next Generation of Physicians 353 Physician Event Reporting … and unsafe situations remains extremely low, despite the increased access to and use of electronic event … We implemented an electronic, Web-based event reporting system at five University of California medical … Our experience validates that of others; specifically, physician event reporting is a largely elusive … Change how event reporting systems are used Traditionally, event reporting was a way to warn institutional

51. Disclosure Checklist | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/checklist5.html
    August 01, 2022 - Identify the adverse event early in the disclosure.   … Explain what is known about why the adverse event occurred; do not speculate.   … Tell the patient whether the adverse event was preventable, if known.   … Explain your role in the event to the patient/family; avoid blaming others or "the system" for the event … Consider ways to involve patients in post-event learning.  

52. Chartbook on Patient Safety (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2020.pdf
    January 01, 2020 - TYPE, category of event (EVENT TYPE), and INITIAL REPORT DATE. … concern (CATEGORY ASSOCIATED WITH EVENT OR UNSAFE CONDITION [EVENT TYPE]) as a percentage of all EVENT … (Event Types) Report Type by Event Type Report Type by Event Type Report Type by Event Type (Data … Extent of Harm by Event Type (Data Table) Event Type by Extent of Harm Event Type by Extent of Harm … Originated Stage Event Originiated Stage Event Originated by Extent of Harm Stage Event Originiated

53. 2024 Network of Patient Safety Databases Chartbook (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-medication-chartbook-2024.pdf
    January 01, 2024 - For example, DE288: “Which of the following best characterizes the event?” … Among Medication or Other Substance event reports with complete event descriptions, the majority … of whether the event resulted in harm to the patient. … question: “What factor(s) contributed to the event?” … FACTOR(S) FOR EVENT were excluded from analyses

54. Network of Patient Safety Databases Chartbook, 2019 (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2019.pdf
    January 01, 2019 - Event-specific Reports The Common Formats include event-specific modules pertaining to nine patient … (EVENT ID); and the REPORT TYPE, category of event (EVENT TYPE), and INITIAL REPORT DATE. … of different EVENT TYPES. … concern (CATEGORY ASSOCIATED WITH EVENT OR UNSAFE CONDITION [EVENT TYPE]) as a percentage of all EVENT … Types) Report Type by Event Type Extent of Harm by Event Type Event Type by Extent of Harm Extent

55. NPSD Dashboards | Agency for Healthcare Research and Quality
    www.ahrq.gov/npsd/data/dashboard/index.html
    September 01, 2024 - generic section that provides an overview of the numbers and categories of various patient safety event … reports and event-specific dashboards that describe in greater depth specific safety events such as … The dashboard charts detail event type, report type by event type, extent of harm by event type, event … originated, and stage of process where event originated by residual harm to the patient.   … Additional Notes As only data submitted in the Common Formats for Event Reporting – Hospitals (CFER-H

56. Network of Patient Safety Databases Chartbook, 2021 (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2021.pdf
    January 01, 2021 - TYPE, category of event (EVENT TYPE), and INITIAL REPORT DATE. … concern (CATEGORY ASSOCIATED WITH EVENT OR UNSAFE CONDITION [EVENT TYPE]) as a percentage of all EVENT … (Event Types) Report Type by Event Type Report Type by Event Type Report Type by Event Type (Data … Extent of Harm by Event Type (Data Table) Event Type by Extent of Harm Event Type by Extent of Harm … Originated Stage Event Originiated Stage Event Originated by Extent of Harm Stage Event Originiated

57. Module 1: Communication and Optimal Resolution (CANDOR) Toolkit Module 1: An Overview of the CANDOR Process
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/module1-overview.pptx
    May 19, 2016 - Unsafe Condition Near Miss No Harm Event CANDOR Event Actual harm to patient Potential patient harm … A CANDOR event is an event that involves unexpected patient harm. … cause of a harm event. … the event. … of a CANDOR Event.

58. Module 7: Resolution | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes7.html
    August 01, 2022 - financial settlement, but might not always lead to resolution of all issues related to the adverse event … However, litigation is not always a patient’s or family’s first instinct after an adverse event, so it … Resolution addresses the needs and concerns of patients after an adverse event. … Patients want to know what will be done to prevent the event from happening again. … Potential future injuries that may result from the adverse event.

59. Grand Rounds Presentation | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/grand-rounds.html
    August 01, 2022 - actually compounded the injury from the event itself. … An event report is completed, which will trigger analysis of the event. … The Investigation: to determine how the event occurred, and how to mitigate that event or even prevent … analysis of an adverse event.  … Host event analysis training using tools from CANDOR.

60. Ventilator-Associated Event Surveillance: Facilitator Guide | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/mvp/modules/vae/surveillance-fac-guide.html
    February 01, 2017 - Ventilator-Associated Event Surveillance: Facilitator Guide AHRQ Safety Program for Mechanically … Ventilated Patients Slide 1: Ventilator-Associated Event Surveillance Say: This module will … focus on ventilator-associated event surveillance and how it can be used in your unit. … Surveillance results can give providers a way to monitor and improve this care by connecting the dots from the event … unit staff can spend time focusing on what went wrong and how to fix it rather than debate whether the event