-
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
-
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
-
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
-
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.
-
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.
-
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.
-
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?
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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?
-
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.
-
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.
-
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 .
-
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