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  1. www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/blood-pressure-narrative.pdf
    December 31, 2018 - Page 2 Event At least one face to face visit (Value Sets: Annual Wellness Exam; Face-to-Face Interaction … Pressure Measure Narrative Description Methodology Measurement Period Eligible Population Ages Event
  2. www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/aspirin-narrative.pdf
    December 31, 2018 - Page 2 Event At least one face to face visit (Value Sets: Annual Wellness Exam; Face-to-Face Interaction … or Another Antithrombotic Description Methodology Measurement Period Eligible Population Ages Event
  3. www.ahrq.gov/teamstepps/instructor/reference/modelchange1txt.html
    March 01, 2014 - Outcomes include level 4 evaluations and sentinel event. … Additional bidirectional arrows connect report card to sentinel event, and connect interventions to report
  4. www.ahrq.gov/hai/cusp/toolkit/morning-briefing.html
    December 01, 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.
  5. www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit1-18.html
    November 01, 2014 - Controlling the rate of change and taking the additional time needed during a Lean event yields better … The schedule of a Lean event may need to be adapted to meet the demands of patient care.
  6. www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/14253-Carayon-draft-1.pdf
    December 01, 2006 - A web-based event reporting system (Patient Safety Net, PSN) was in place. … Hospital web-based event report data (Patient Safety Net [PSN] Data) We monitored hospital event reports … They included event and follow-up dates; event notes; whether patient harm may have occurred as a result … Most multiple sequences had two event rows of data (range 2-8). … JCAHO Sentinel Event Statistics, June 24, 2003.
  7. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/hotline/healthcare-safety-hotline-appendixc.pdf
    July 01, 2015 - event taxonomy using drill-down (multilevel) menus. … • Event ID number. • RSO status. • Community. … An incident is an event that reaches a patient; that is, an event that exposes a patient to harm, regardless … A near miss is an event that does not reach a patient. … Unknown 8.7.1 What factor(s) contributed to the event?
  8. www.ahrq.gov/sites/default/files/wysiwyg/research/publications/pubcomguide/Location-Release-fillable-form.pdf
    April 01, 2024 - Location Release for [Name of the LOCATION] For [Purpose or Name of Event] The undersigned (“Administrator … : Date: Company Address: Date: Company Name: Date_2: Company Address: Location Name: Event
  9. www.ahrq.gov/patient-safety/capacity/candor/demo-program/grants/summary.html
    May 01, 2016 - ) expanded our understanding of the potential role for patients and their family members in adverse event … of an existing program, UIC Medical Center showed improvements in malpractice outcomes and adverse event … Development of an adverse event debriefing method Based on 62 interviews conducted using a debriefing … provide critical information about adverse events that is not otherwise known to those analyzing the event … in this area added to the existing knowledge base regarding what patients want following an adverse event
  10. www.ahrq.gov/news/newsroom/case-studies/ktcoe31.html
    October 01, 2014 - The event provided participants with scientific evidence evaluating the safety and effectiveness of newer … Kimball Medical Center was one of 171 participants in the Web conference event, which targeted clinical
  11. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Riley_59.pdf
    April 06, 2008 - Therefore, the Act has the potential to create an event reporting system that provides feedback for … investigation to assess associated event or incident causal factors. … • Was this a one-time event or a point on a trend line? … • Was this a one-time event or a point on a trend line? … The attributes of medical event reporting systems: Experience with a prototype medical event reporting
  12. www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospitalsurvey2-form.docx
    June 09, 2016 - Instructions This survey asks for your opinions about patient safety issues, medical error, and event … injuries or adverse events resulting from the processes of healthcare delivery. · A “patient safety event … 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 1 2 3 4 5 9 … Hospital management seems interested in patient safety only after an adverse event happens 1 2 3
  13. www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/SOPS-Hospital-Survey-2.0-English-05.18.21.docx
    June 09, 2016 - Instructions This survey asks for your opinions about patient safety issues, medical error, and event … injuries or adverse events resulting from the processes of healthcare delivery. · A “patient safety event … 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 1 2 3 4 5 9 … Hospital management seems interested in patient safety only after an adverse event happens 1 2 3
  14. www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/high-reliability-journey-slides.pptx
    September 26, 2023 - complex, high-risk environments Fewer than anticipated accidents or events of harm An “accident or event … of harm” could be more broadly defined as any event that causes disruption to safe and reliable operations … across the system Unclear Policy Error in Data Report Unjust Response to Adverse Event Operating … Leadership Engagement Stop the Line Close Call (CC)/Adverse Event (AE) Reporting These documents
  15. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Flack.pdf
    January 01, 2005 - This paper will discuss FDA’s approach in developing the MedSun adverse event reporting program, including … numbers, the patient outcome, or preexisting clinical problems that could have contributed to the event … The barrier to the movement of information within a facility is that an adverse event report made by … Step 3: Train the MedSun representatives to write complete and accurate adverse event reports. … A short video is being produced that depicts a device-related adverse event and demonstrates why it
  16. www.ahrq.gov/patient-safety/resources/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?
  17. www.ahrq.gov/patient-safety/settings/hospital/candor/impguide/apa.html
    August 01, 2022 - measures that reflect the culture of an organization include: Length of time to report the adverse event … Length of time it takes to disclose the event. … Length of time to complete investigation and analysis of the event. Number of claims asserted.
  18. www.ahrq.gov/patient-safety/settings/hospital/candor/modules/worksheet2.html
    August 01, 2022 - measures that reflect the culture of an organization include: Length of time to report the adverse event … Length of time it takes to disclose the event. … Length of time to complete investigation and analysis of the event. Number of claims asserted.
  19. www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/resources/tools/reduce/4-things.html
    March 01, 2017 - * Go to CDC's January 2016 "Urinary Tract Infection (UTI) Event for Long-term Care Facilities," … Urinary Tract Infection (UTI) Event for Long-term Care Facilities .
  20. www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/20150122/1_carla_zema_intro.pdf
    January 22, 2015 - Question 10 www.cahps.ahrq.gov Accessing Presentations 11 www.cahps.ahrq.gov Accessing Event … To Ask a Question Accessing Presentations Accessing Event Materials

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