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Showing results for "event".

401. Using Probabilistic Risk Assessment to Model Medication System Failures in Long-term Care Facilities (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Comden.pdf
     January 01, 2003 - An ST– PRA risk tree starts with a top-level event, which is the undesirable outcome (e.g., a wrong … Risk modeling teams then identify the failures that link together, leading to the top-level event. … Experience indicates that these team estimates are more accurate than rates derived from event data, … an undeveloped event. … the same outcome—they can only describe what occurred in the event under study.

402. CRP Certification: Promoting Accountability and Learning After Adverse Events (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/gallagher5-report.pdf
     January 01, 2024 - through transparency and disclosure along with proactively offering compensation when the adverse event … patient-centered accountability but also improve quality and safety through analysis of the adverse event … with the patient, event analysis and identification of gaps that contributed to the event, demonstrated … BETA has defined five domains – culture of safety, rapid event response and analysis, communication … The initial conversation with the patient and/or family occurred the same day as the event in 44% of

403. Hospital Survey on Patient Safety Culture Version 2.0 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospitalsurvey2-form.pdf
     August 26, 2019 - Instructions This survey asks for your opinions about patient safety issues, medical error, and event … • A “patient safety event” is defined as any type of healthcare-related error, mistake, or incident … When an event is reported in this unit, it feels like the person is being written up, not the problem … In this unit, we are informed about changes that are made based on event reports ........... … Hospital management seems interested in patient safety only after an adverse event happens ........

404. Detailed Findings | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/demo-program/grants/findings.html
     August 01, 2022 - and resolution program at the five participating hospitals: 3 An initial disclosure of an adverse event … with only a short time elapsing between the first communication with patients and families about the event … Patient and family member experience of medical harm after adverse event. 6 Seventy-two patients and … About half of participants indicated they would prefer to engage in adverse event analysis through a … Typically, risk managers review claims by themselves long after an event occurs; having a team review

405. Final Progress Report: Automated Image Analysis for the Prevention of Radiotherapy Delivery Errors (pdf file)
     www.ahrq.gov/sites/default/files/2024-11/lamb-report.pdf
     January 01, 2024 - Key Words: radiotherapy, IGRT, medical event Purpose. … This project will develop an automated, on-line never event prevention system (NEPS) that will interlock … Methods Aim 1: Development of Algorithms We developed never-event detection algorithms for planar … Furthermore, we developed a new algorithm for never-event detection using Cone Beam Computed Tomography … All images flagged by the algorithm were reviewed by human experts to determine if a never-event was

406. Hospital Survey on Patient Safety Culture Version 2.0 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/SOPS-Hospital-Survey-2.0-5-26-2021.pdf
     January 01, 2021 - Instructions This survey asks for your opinions about patient safety issues, medical error, and event … • A “patient safety event” is defined as any type of healthcare-related error, mistake, or incident … When an event is reported in this unit, it feels like the person is being written up, not the problem … In this unit, we are informed about changes that are made based on event reports ........... … Hospital management seems interested in patient safety only after an adverse event happens .......

407. Appendix A: References and Available Abstracts | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/shuttered/acfselection/appendixa.html
     July 01, 2018 - BACKGROUND: The terrorist bombings in London on July 7, 2005, produced the largest mass casualty event … of these actions, hospitals have been working vigorously to ensure that they would be "ready" in the event … The team, prepared and equipped for deployment four days after the event, arrived at its destination … The ability to deliver optimal medical care in the setting of a disaster event, regardless of its cause … The types and needs of patients following such an extensive event have not been well described.

408. Physician Champion Checklist | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/modules/cusp/physician-checklist.html
     January 01, 2017 - Ensure infection control reports of ventilator-associated event (VAE) rates are reviewed with unit staff … monthly; contribute to each event investigation process.

409. Medications Supplement Dashboard Data 2023 (xls file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/Medications_Supplement_Dashboard_Data_2023.xlsx
     January 01, 2023 - Dashboard Name Worksheet Name Report Type by Description of Substance Event Med_1 Stage Event … Description of substance event? … Med_2 Med_2: Stage Event Originated by Report Type Report Type Stage event originated? … Med_5 Med_5: Stage Event Originated by Incorrect Action - Incidents Incorrect Action(s) Stage event … Med_10 Med_10: Stage Event Originated by Incorrect Action - Near Misses Incorrect Action(s) Stage event

410. Mod03-Gap-Analysis-Guide (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module3/mod03-gap-analysis-guide.pdf
     April 01, 2016 - Has an organized process to assess behavior related to the event been established? e. … Is supportive care provided to the caregiver within 24 hours of the event? f. … Is an attempt made to disclose within the first 24 hours following an adverse event? … 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?

411. Simulation Facguide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/situ/simulation_facguide.docx
     May 01, 2017 - The participants are asked to treat the simulated event like an actual patient situation. … Slide 11 SAY: A well-built scenario generally consists of three to five event sets. … 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 … Each event set usually has one trigger.

412. Final Progress Report: Workload effects on response time to life-threatening arrhythmias (pdf file)
     www.ahrq.gov/sites/default/files/2024-09/segall-report.pdf
     January 01, 2024 - telemetry technicians using a combination of real patient data and a simulated patient experiencing a VF event … We timed the event to be well into the data collection period (after over 3 hours), to allow participants … or 1 (performed) for each required task, for which multiple tasks are associated with each patient event … on importance (e.g., a larger weight was assigned to the task of making a phone call to report an event … Ventricular fibrillation (VF) Make call using ‘red’ phone 4 Asystole Stress urgency and gravity of event

413. 014-Bcx-Algorithm-Decision-Support-Tool (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/014-bcx-algorithm-decision-support-tool.docx
     October 01, 2024 - algorithm differentiates between initial indications for blood cultures in the setting of a new clinical event … For blood cultures being considered in the setting of a new clinical event: 1.

414. Regulation of Health Policy: Patient Safety and the States (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Weinberg.pdf
     March 01, 2004 - problem, and have recommended eliminating the traditional clinical boundaries that discourage adverse event … (The abbreviation AE will be used throughout the paper to denote “adverse event,” “medical error,” etc … With respect to specific State provisions, Connecticut defines AE as “any event that is identified on … In Maine, a sentinel event includes “An unanticipated death; or a major permanent loss of function … ,” and from whose perspective—the physician, health plan, or patient—is the event adverse.

415. Tool: Call-Out | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps-program/curriculum/communication/tools/callout.html
     May 01, 2023 - Afterwards, consider how the use of call-outs helped the team during an emergent event:  How did … the call-outs made by the nurse and intern aid the team during this emergent labor and delivery event

416. Use Simulation To Adopt and Adapt Best Practices | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/simulation-issue-brief4.html
     July 01, 2024 - failure modes and effects analysis (FMEA), 18 probabilistic risk assessment (PRA), responses to adverse event … Simulation-Based Training for Emergency Responses by Practitioners in an Ambulatory Care Setting After an actual event

417. How PSOs Help Health Care Organizations Improve Patient Safety Culture (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/npsd-patient-safety-culture-brief.pdf
     September 01, 2016 - One way to drive improved culture is to develop the norm of routine safety event reporting. … that encourage and facilitate patient safety Program Brief Network of Patient Safety Databases event … Several PSOs provide members a confidential analysis of patient safety event data, and provide forums … PSOs encourage voluntary patient safety event reporting by offering technical assistance and the … a series of calls to walk their members through procedures for efficiently and safely submitting event

418. Major Study Finds Significant National Patient Safety Improvement | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/press-releases/significant-patient-safety-improvement.html
     July 01, 2022 - Researchers found significant decreases in in-hospital adverse event rates for heart attack, heart failure … In the observed data for 2010 and 2019, adverse event rates fell 36 percent for heart attack patients … After adjustment, the relative risk of experiencing an adverse event diminished for all five patient

419. Network of Patient Safety Databases Falls Chartbook, 2023 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-falls-chartbook-2023.pdf
     January 01, 2023 - • The NPSD is a summary of the elements in Hospital Common Formats Event Reports for specific types … • While it is believed that the Common Formats for Event Reporting-Hospitals (CFER-H) are primarily … Data and Analysis Available at the NPSD Submission of patient safety event data by providers to PSOs … Hence, the event report data submitted to the NPSD cannot be used to calculate the actual incidence … Event Types represent the distinct modules of the CFER-H (e.g., Fall).

420. Implementing Near-Miss Reporting and Improvement Tracking in Primary Care Practices: Lessons Learned | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/liability/crane.html
     August 01, 2017 - (as opposed to an adverse event or an error that had no potential for patient harm) and how to use the … to make sure that the report was a near-miss (i.e., no harm came to the patient) and not an adverse event … their practice reported at least 10 near-miss events a month and identified at least one near-miss event … In fact, many of the near-miss event reports contained statements from those submitting the report that … Does error and adverse event reporting by physicians and nurses differ?