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www.ahrq.gov/sites/default/files/2024-01/fairbanks-report.pdfJanuary 01, 2024 - Specific Aim 2 Evaluate the impact of the EPh Program Hypothesis: The overall event (adverse drug event … If an event or potential event was identified, the case was forwarded to the Case Review Committee. … The event rate was calculated based on number of patients who experienced an event per total number … Thus, if a single patient had two events, they would only count as one event case. … If an event or potential event was identified, the case was forwarded to the Case Review Committee.
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www.ahrq.gov/teamstepps/simulation/traininggd2.htmlMarch 01, 2018 - Simulation Training Course At the end of this training, participants will be able to: Apply the Event-Based … Event Set With Trigger and Distracters 6. … “Event-based approach to training (EBAT).” … simulation-based training in emergency medicine: The simulation modules for assessment of resident targeted event … “Promoting teamwork: An event-based approach to simulation-based teamwork training for emergency medicine
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Scoring Different Kinds of Health Care Quality Measures | Agency for Healthcare Research and Quality
www.ahrq.gov/talkingquality/translate/scores/scoring.htmlJune 01, 2016 - The choice of reporting only “yes” or “no” answers can be tricky if your measure captures a negative event … Do you want to tell people how often this event happened or how often it did not happen? … Experience indicates that in this case, saying how often a patient safety event did happen will be -
Puh-Factraining-Guide (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-factraining-guide.docxNovember 24, 2014 - Nursing home staff generally do a good job of investigating and following up after an adverse event, … It is more difficult for staff to identify which residents are at risk for a future adverse event or … at high risk or had a recent change in risk, would we do things differently to intervene before the event … The questions in each Self-Assessment are tailored to the On-Time adverse event being addressed. … Discussion questions are tailored to the On-Time adverse event being addressed. -
www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/guide.htmlDecember 01, 2017 - Nursing home staff generally do a good job of investigating and following up after an adverse event, … It is more difficult for staff to identify which residents are at risk for a future adverse event or … Investigate root causes when an adverse event occurs. … The questions in each Self-Assessment are tailored to the On-Time adverse event being addressed. … Discussion questions are tailored to the On-Time adverse event being addressed.
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www.ahrq.gov/news/newsroom/case-studies/cp31101.htmlOctober 01, 2014 - They then will be placed on a rotating call list to be used in the event of emergencies. … to provide basic respiratory care and ventilator management to adult patients in any mass casualty event
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/physician-checklist.docxJanuary 01, 2017 - Ensure infection control reports of ventilator-associated event (VAE) rates are reviewed with unit staff … monthly; contribute to each event investigation process 8.
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Morningbriefing (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/morningbriefing.docAugust 07, 2012 - After receiving an update on the patients, proceed to Question II, unless there was an adverse event. … If an adverse event occurred, you should also use the Learn From Defects Form. II. -
www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/20150917/dale_shaller_intro.pdfSeptember 17, 2015 - Question 7 www.cahps.ahrq.gov Accessing Presentations 8 www.cahps.ahrq.gov Accessing Event … To Ask a Question Accessing Presentations Accessing Event Materials Webcast Agenda
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/19118-Lord-draft-1.pdfAugust 30, 2011 - Operational Definition A call for the RRT received by telecom- munications Any cardiac event … that required CPR**** or ACLS* was considered as well as all asystole or PEA** Any cardiac event … The responding Hospital Medicine clinicians were responsible for filling out the event form. … There were several possible reasons for the low event record completion rate. … When the event occurred during a busy day, clinicians may have simply forgotten to complete the event
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www.ahrq.gov/cpi/about/nac/naa-snac-recommendations.htmlFebruary 01, 2024 - Safety plans will include provisions for patient access to submit safety concerns, inclusion in event … include: Increase in the percentage of claims identified in reporting systems within 48 hours of an event … Implementation of robust communication and resolution programs with reported event feedback provisions
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/index.htmlJuly 01, 2023 - The specific event presented in the video is postpartum hemorrhage, but the CUSP techniques can be used … for any perinatal safety event.
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www.ahrq.gov/sites/default/files/2024-12/weinger2-report.pdfJanuary 01, 2024 - NRE are defined as any event that is perceived to deviate from ideal care for that specific patient … An NRE is defined as any event that is perceived by care providers or skilled observers to be unusual … of prospective studies but can be used stand-alone for active event surveillance. … The image on the left shows a desaturation (low oxygen) event after extubation. … A rigorous taxonomy of event type and impact, informed by taxonomic research of anesthesia events 20
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www.ahrq.gov/news/newsroom/case-studies/cquips0501.htmlOctober 01, 2014 - and the team members from the Connecticut Department of Public Health studied Connecticut's adverse event … Committee, which was developing formal recommendations to enhance the effectiveness of the state's adverse event
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www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-care-transitions3.htmlJune 01, 2023 - academic medical centers, one survey 57 showed that 87 percent of residents recalled at least one adverse event … Not surprisingly, at least 20 percent of patients discharged from the ICU experience an adverse event … despite significant process variation across sites, almost all resident physicians recalled an adverse event
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions3.htmlJune 01, 2023 - academic medical centers, one survey 57 showed that 87 percent of residents recalled at least one adverse event … Not surprisingly, at least 20 percent of patients discharged from the ICU experience an adverse event … despite significant process variation across sites, almost all resident physicians recalled an adverse event
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www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/education-bundles/strategies-slides.htmlMarch 01, 2017 - 2 According to Sentinel Event data compiled by the Joint Commission between 1995 and 2005, ineffective … Root Causes by Event Type, 2004-2Q 2014. Sentinel Event Data. … Root Causes by Event Type, 2004-2Q 2014. Sentinel Event Data.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Woolever.pdfJanuary 01, 2001 - Woolever Abstract Background: In response to the occurrence of a sentinel event—a medical error with … , or a sentinel event. … An adverse event has minimal effect on the involved patient and does not result in any significant … event” in 1998 and 2001; P = 0.069 0 1 2 3 4 5 6 7 8 19 98 20 01 p < 0.005 0 50 100 150 … 200 250 300 Total Rep Near Miss Adv Event Sent Event 1998 2001 Advances in Patient Safety: Vol
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/sops101-4-famolaro-2018.pdfJanuary 01, 2018 - Hospital CAHPS patient experience • Hospital SOPS to AHRQ Patient Safety Indicator (PSI) adverse event … Hospital SOPS & PSI Adverse Event Rates Higher patient safety culture scores associated with lower … adverse event rates r = -.36 0 2 4 6 8 10 12 14 16 18 40% 45% 50% 55% 60% 65% 70% 75% 80% … SOPS to Other Outcomes Hospital SOPS & Hospital CAHPS Patient Experience Hospital SOPS & PSI Adverse Event
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Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention Measure Narrative (pdf file)
www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/tobacco-narrative.pdfDecember 31, 2018 - Page 2 Event At least two visits (Value Sets: Health & Behavioral Assessment – Individual; Health … Intervention Measure Narrative Description Methodology Measurement Period Eligible Population Ages Event
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