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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Prologue_Henriksen_Vol1.pdf
July 10, 2008 - Challenges of reporting quickly give rise to challenges of encoding and organizing the adverse
event … Strategies and efforts aimed at adverse event surveillance, creating useable taxonomies, and
addressing … paper examines the perceptions of health care leaders and news media professionals related to
adverse event
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hsops2-pt2_transition_apx.pdf
September 01, 2019 - (F3R)
Hospital management seems interested in
patient safety only after an adverse event
happens. … (C3)
We are given feedback about changes put into
place based on event reports. … (G1)
(No event reports, 1 to 2, 3 to 5, 6 to 10, 11 to 20,
21 event reports or more)
45% 44% 1% … (C3)
We are given feedback about
changes put into place based on
event reports. … (G1)
(No event reports, 1 to 2, 3 to 5, 6
to 10, 11 to 20, 21 event reports
or more)
45% 44% 1%
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-factraining-guide.pdf
December 15, 2016 - 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 … 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/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/situ/simulation_facguide.pdf
May 01, 2017 - The participants are asked to treat the
simulated event like an actual patient situation. … Event sets can be
created by breaking a clinical situation into
chunks. … and applying clinical
treatments to respond to an unfolding
emergency, and a third event set might … Each event set usually has one trigger. … In addition to a trigger
and expected response, an event set often
contains a distractor, which is
-
www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/16463-Gurwitz-report.pdf
January 01, 2011 - not statistically significant; the incident rate ratio for
any preventable warfarin-related adverse event … Reviewers independently classified incidents, including whether a warfarin-related adverse
event or … a potential warfarin-related adverse event was present, whether the event was
preventable, and the severity … of the event. … The adjusted incident rate ratio (IRR) for
any preventable warfarin-related adverse event was 0.87 (
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/report/ref.html
June 01, 2010 - Rosenthal J, Takach M. 2007 Guide to State adverse event reporting systems. … As used in this report, the term "serious reportable adverse health event" is defined as an event that … an undesirable outcome (death or serious harm) or significant potential for such an outcome, and the event
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospitalsurvey2-items.pdf
August 01, 2019 - 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.
-
www.ahrq.gov/patient-safety/settings/hospital/candor/videos/physicians.html
August 01, 2022 - demonstrates an example of emotional support provided for the physician caregiver after an adverse event
-
www.ahrq.gov/patient-safety/settings/hospital/candor/videos/nurses.html
August 01, 2022 - video demonstrates an example of emotional support provided for the nurse caregiver after an adverse event
-
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-136-section-2-tech-specs.pdf
January 01, 2012 - Other qualifying events after the fifth birthday at time of event:
One or more prior ambulatory visits … Exclude those children who have previously had an event
(include only the first hospitalization or ED … Qualifying events after the fifth birthday at time of event:
1) One or more prior ambulatory visits … were continuously
enrolled for at least 6 continuous months before the month in
which the qualifying event … Use the first such event for
each child when assessing each numerator.
-
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-0232-technicalspecs.pdf
February 04, 2020 - Event/Diagnosis An outpatient care visit and BMI ≥85th percentile. … Reporting of systolic and/or diastolic blood pressure only is not sufficient to qualify as a numerator
event
-
www.ahrq.gov/news/blog/ahrqviews/improving-heart-health.html
February 01, 2019 - strategy: increasing the use of cardiac rehabilitation among patients who have experienced a coronary event … Each year, about 965,000 Americans experience a coronary event.
-
www.ahrq.gov/evidencenow/projects/heart-health/evidence/cholesterol.html
March 01, 2021 - CVD) in adults aged 40 to 75 years, with at least one CVD risk factor and an increased risk of a CVD event … The USPSTF recommended discussing statin use in similar patients with more moderate risk of a CVD event … cardiovascular disease (CVD) and for those who have one or more CVD risk factors with a calculated 10-year CVD event
-
www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/20150317/dale_shaller_intro.pdf
March 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
CAHPS Health Plan Survey
CAHPS
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Faltz_56.pdf
March 27, 2008 - to implement quality improvement projects.15
In January 2006, after a serious wrong-side surgery event … The distribution of causative factors was compared to data
from the Joint Commission’s Sentinel Event … Sentinel Event Alert, Issue 6. … Sentinel Event Alert, Issue 24. … Sentinel event trends: Wrong-site surgeries reported
by year.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Kohl.pdf
April 01, 2004 - and future comparability with reports of the same
adverse event in other studies. … Vaccine Adverse Event Reporting System. … Fever
as an adverse event following immunization: case
definition and guidelines of data collection … Hypotonic-hyporesponsive episode (HHE) as an
adverse event following immunization: case definition … Levels of evidence for a reported event meeting the case definition
Figure 1.
-
www.ahrq.gov/news/newsroom/case-studies/coe1202.html
August 01, 2012 - Medical Technologist for the Association, over 75 of AHRQ's EHC summaries were distributed at this event … This event, called "EXPO Diabetes," is the only convention in Puerto Rico fully dedicated to diabetes
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/measuredesc-dailyearlymobility-slides.pptx
January 01, 2017 - Delirium
Early mobility (EM)
Perceived barriers to EM
Physical/occupational therapy (PT/OT)
Adverse events
Event … Measures ‹#›
AHRQ Safety Program for Mechanically Ventilated Patients
Events
Did the patient have an “event … Event codes are listed on the back of the data collection sheet
Can include up to three events if necessary … Early Mobility Measures ‹#›
AHRQ Safety Program for Mechanically Ventilated Patients
Event Codes … (no delirium)
Percentage of incorrectly reporting CAM-ICU/ICDSC/ASE UTA (Unable to Assess)
Adverse event
-
www.ahrq.gov/news/newsroom/case-studies/201414.html
August 01, 2014 - As part of that education program, the Hospital Center determined that its "serious safety event" rate … When the second survey was conducted in 2012, the serious safety event rate decreased by 44 percent.
-
www.ahrq.gov/patient-safety/reports/hotline/lessons5.html
May 01, 2016 - an 8 th grade (or lower) reading level in all materials aimed at potential respondents: the patient event … and complaint departments) and information about patient safety concerns from staff (e.g., adverse event … since the organizations goal is to be in contact with the patients as quickly as possible after an event … Legal and regulatory obstacles to soliciting, storing, analyzing, and sharing event reports are manageable … The physicians who classified the patient event reports according to event type, harm, duration of harm