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Total Results: 5,333 records

Showing results for "event".

81. Patient Safety Concerns Dashboard (xls file)
    www.ahrq.gov/sites/default/files/wysiwyg/npsd/Generic_Dashboard_Data_2020.xlsx
    January 01, 2020 - Dashboard Name Worksheet Name Percentage of Patient Safety Concerns (Event Types) Gen_1 Report … Type by Event Type Gen_2 Extent of Harm Gen_3 Extent of Harm by Event Type Gen_4 Event … /www.ahrq.gov/npsd/data/dashboard/generic.html Gen_1 Gen_1: Percentage of Patient Safety Concerns (Event … Type Event Type Report Type Percentage Frequency Total Blood or Blood Product Incident 72.5% 13,322 … Gen_5 Gen_5: Event Type by Extent of Harm Event Type Extent of Harm Percentage Frequency Total Blood

82. Sensemaking and Learn From Defects for Perinatal Safety | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-slides.html
    July 01, 2023 - Each person brings their experience of that event/issue to the discussion. … At the top of the tree and at the top row is the discovery event. … The discovery event addresses what happened. … Providers must also correct the factors that contribute to an event. … The attributes of medical event-reporting systems: Experience with a prototype medical event-reporting

83. Patient Safety Concerns Dashboard (xls file)
    www.ahrq.gov/sites/default/files/wysiwyg/npsd/Generic_Dashboard_Data_2019.xlsx
    January 01, 2019 - Dashboard Name Worksheet Name Percentage of Patient Safety Concerns (Event Types) Gen_1 Report … Type by Event Type Gen_2 Extent of Harm Gen_3 Extent of Harm by Event Type Gen_4 Event … Type Event Type Report Type Percentage Frequency Blood or Blood Product Unsafe Condition 1.6% 199 … Gen_4 Gen_4: Extent of Harm by Event Type Event Type Extent of Harm Percentage Frequency Blood or … Gen_5 Gen_5: Event Type by Extent of Harm Event Type Extent of Harm Percentage Frequency Blood or

84. Sensemaking and Learn From Defects for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-fac-guide.html
    July 01, 2023 - Sensemaking tools supply a systematic approach to event reporting. … of "why's" to reach the root causes of the event. … the event from reaching the patient. … Harm that did not happen—No-harm event. Event did not reach the patient—Near-miss event. … The tree is an interpretation of the event.

85. PowerPoint Presentation
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module7/module7-resolution-facilitator.pptx
    August 24, 2015 - Resolution addresses the needs and concerns of patients after an adverse event. … Patients want to know what will be done to prevent the event from happening again. … Determine fair and reasonable compensation for the patient/family after an adverse event. … Potential future injuries that may result from the adverse event. … Length of time it takes to disclose the event.

86. Event Investigation and Analysis Guide: Appendix E | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/capacity/candor/modules/guide4/ape.html
    February 01, 2017 - Event Investigation and Analysis Guide: Appendix E As you may know, a patient care incident … occurred on (insert date) involving (brief description of event). … An in-depth review of the event is complete.

87. AHRQ Quality Indicators Prioritization Worksheet Example (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c2_combo_prioritizationworksheetexample.pdf
    June 29, 2016 - Anticipated average cost for one case with this event The total annual cost of this event to … Anticipated average cost for one case with this event The total annual cost of this event to … Anticipated average cost for one case with this event The total annual cost of this event to … Anticipated average cost for one case with this event The total annual cost of this event to … Anticipated average cost for one case with this event The total annual cost of this event to

88. CommonSpirit Health Expands CANDOR Toolkit Across Entire Health System | Agency for Healthcare Research and Quality
    www.ahrq.gov/news/newsroom/case-studies/202104.html
    October 01, 2021 - or potential adverse event, and officials estimate 85 patients were spared the additional harm of not … “It’s all about how to communicate an adverse event or a potential adverse event promptly and candidly … "Our goal is to notify the patient and family within 60 minutes of an event," Pelletreau explained. … When an unexpected event occurs, those situations are tracked by a core management team consisting of … “CANDOR is absolutely the right approach for all involved in an adverse event,” Pelletreau said.

89. Ventilator-Associated Event Surveillance: Slide Presentation | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/mvp/modules/vae/surveillance-slides.html
    February 01, 2017 - Ventilator-Associated Event Surveillance: Slide Presentation AHRQ Safety Program for Mechanically … Patients Slide 1: AHRQ Safety Program for Mechanically Ventilated Patients Ventilator-Associated Event

90. PowerPoint Presentation
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/grand-rounds-presentation-slides.pptx
    January 01, 2014 - actually compounded the injury from the event itself. … An event report is completed, which will trigger analysis of the event. … The Investigation: to determine how the event occurred, and how to mitigate that event or even prevent … analysis of an adverse event. … place after event analysis is completed.

91. Mod01-Grand-Rounds-Slides (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/grandrounds/mod01-grand-rounds-slides.pdf
    April 01, 2016 - actually compounded the injury from the event itself. … An event report is completed, which will trigger analysis of the event. … The Investigation: to determine how the event occurred, and how to mitigate that event or even prevent … analysis of an adverse event. … ■ Host event analysis training using tools from CANDOR.

92. Device or Medical/Surgical Supply including Health Information Technology Dashboard (xls file)
    www.ahrq.gov/sites/default/files/wysiwyg/npsd/Device_Dashboard_Data_2019.xlsx
    January 01, 2019 - Harm Device_1 Type of Device Device_2 Type of Device by Extent of Harm Device_3 Device Event … Description Device_4 Device Event Description by Extent of Harm Device_5 HIT Device Related … to Event or Unsafe Condition Device_6 HIT Device Related to Event or Unsafe Condition by Extent … Device_4 Device_4: Device Event Description Device Event Description Percentage Frequency Device defect … Device_6 Device_6: HIT Device Related to Event or Unsafe Condition HIT Device Percentage Frequency

93. Device or Medical/Surgical Supply including Health Information Technology Dashboard (xls file)
    www.ahrq.gov/sites/default/files/wysiwyg/npsd/Device_Dashboard_Data_2020.xlsx
    January 01, 2020 - Description Device_4 Device Event Description by Extent of Harm Device_5 HIT Device Related … to Event or Unsafe Condition Device_6 HIT Device Related to Event or Unsafe Condition by Extent … Device_4 Device_4: Device Event Description Device Event Description Percentage Frequency Total Unknown … Device_6 Device_6: HIT Device Related to Event or Unsafe Condition HIT Device Percentage Frequency … Device_7 Device_7: HIT Device Related to Event or Unsafe Condition by Extent of Harm HIT Device No

94. Notification of Adverse Event: Video | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/videos/notification.html
    August 01, 2022 - Notification of Adverse Event: Video AHRQ Communication and Optimal Resolution Toolkit Communication … This video demonstrates an example of caregivers notifying the CANDOR team of an adverse event.

95. How Does the NPSD Work? | Agency for Healthcare Research and Quality
    www.ahrq.gov/npsd/how-does-npsd-work/index.html
    February 01, 2024 - Patient Safety Organization Privacy Protection Center (PSOPPC) using the AHRQ Common Formats for Event … The AHRQ Common Formats for Event Reporting can be used to report patient safety concerns, a term that … Presently, data must comply with AHRQ's Common Formats for Event Reporting (CFER) in order to be accepted

96. Learning-From-Antibiotic-Adverse (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/learning-from-antibiotic-adverse.docx
    June 01, 2021 - Antibiotic Use Learning From Antibiotic-Associated Adverse Events An antibiotic-associated adverse event … is any event or situation that you would not want to happen again because it either caused your patient … We use a simple four-step approach with the goal of turning a problem, near-miss, or adverse event into … Identify the antibiotic-associated adverse event. (What happened?) Step 2. … Identify the antibiotic-associated adverse event. (What happened?) 2.

97. Device or Medical/Surgical Supply including Health Information Technology Dashboard (xls file)
    www.ahrq.gov/sites/default/files/wysiwyg/npsd/Device_Dashboard_Data_2021.xlsx
    January 01, 2021 - Description Device_4 Device Event Description by Extent of Harm Device_5 HIT Device Related … to Event or Unsafe Condition Device_6 HIT Device Related to Event or Unsafe Condition by Extent … Device_4 Device_4: Device Event Description Device Event Description Percentage Frequency Total Unknown … Device_5 Device_5: Device Event Description by Extent of Harm Device Event Description No Harm Percentage … Device_6 Device_6: HIT Device Related to Event or Unsafe Condition HIT Device Percentage Frequency

98. Affinity-Details-Improving-Support-Women (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/affinity-details-improving-support-women.pdf
    May 01, 2021 - EVENT SUMMARY LEARNING COMMUNITY AFFINITY GROUP | SUMMARY AT-AT-GLANCE | 1 AFFINITY GROUP DETAILS … EVENT SUMMARY LEARNING COMMUNITY AFFINITY GROUP | SUMMARY AT-AT-GLANCE | 2 OVERALL EVENT THEMES … Lack of cardiologist referrals and logistical challenges were also identified by event participants … Additional Details Event slides and a recording of the event provide additional details that complement … The event slides and recording are available online at: TAKEheart.ahrq.gov

99. Patient, Family Member, and Clinician Perceptions of Disclosure of Adverse Events in Labor and Delivery | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/resources/liability/baker.html
    August 01, 2017 - Type of event seemed to affect what failures clinicians indicated should be disclosed, while type of … event had little effect on what failures patients and family members indicated should be disclosed. … Last, we interviewed 12 clinicians about the common failures that can occur leading to each event. … Table 7 presents the correlation among the mean rankings for each event presented in Table 6. … If adverse event type had no effect on ranking failure, these correlations would be high.

100. AHRQ NAC Meeting | Agency for Healthcare Research and Quality
     www.ahrq.gov/cpi/about/organization/nac/webex-instructions.html
     March 01, 2018 - MTID=ea9f5703b56b58af33bf62dabd3871465 Step 2: Provide the event password: Erf4rQZ4 Note that the … Should you have any problems accessing WebEx during the event, please contact Amy Rabin at amy.rabin … Audio Conference Information To receive a call back, provide your phone number when you join the event