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www.cahps.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-126-section-2-technical-specs.pdf
April 30, 2018 - Event/
diagnosis
Children on any antipsychotic medication for 90 days or more (Table 1).
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www.cahps.ahrq.gov/hai/pfp/hacrate2013.html
January 01, 2018 - MPSMS data provide inpatient mortality data for the patients who experienced each type of adverse event … , and for patients who were exposed to risk for the event. 13 These MPSMS mortality data were of interest … For pressure ulcers and falls, 100 percent of patients are exposed to risk for the event; but for other … event types, such as CLABSIs, only a fraction of patients are exposed to risk for the event. … patients who received a central line as part of their inpatient care are considered at risk for the event
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www.cahps.ahrq.gov/teamstepps/instructor/fundamentals/module4/igleadership.html
March 01, 2019 - Discussion:
What event necessitated the need for the huddle? … Analysis of why the event occurred, what worked, and what did not work. … Debriefs can be a brief (about 3 minutes or less) team event, typically initiated and facilitated by … Held debrief to recap event and share lessons learned. … Use of these tools leads to gaining a shared model or understanding of a situation or event (i.e., shared
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-177-section-2-technical-specs.pdf
May 23, 2014 - Event/ At least two antipsychotic medication dispensing events (Table 1), regardless if they are the … Event/diagnosis At least two antipsychotic medication dispensing events (Table XXX-A), regardless if
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www.cahps.ahrq.gov/hai/cauti-tools/archived-webinars/cauti-sustainability-slides.html
December 01, 2017 - at unexpected events, data results, and outcomes to determine all of the underlying causes of the event … Event Analysis
Team notification – Nurse Manager, Medical Director, and Frontline staff notification … – email and huddle
Infection Prevention Council report out
Slide 66
Event Analysis Tool
Image … : Screen shot of a CAUTI Event Analysis form. … Slide 80
Identifying Defects: Defects Can Come From Many Different Sources
Staff feedback
Event
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-241-bmi-communication-section-2-tech-specs.pdf
February 24, 2020 - Event/Diagnosis An outpatient care visit and BMI ≥85% percentile.
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-145-materials-vi-a.pdf
March 01, 2011 - during continuous enrollment period
Anchor Date
Date of ADHD diagnosis at the physician visit
Event … with ADHD (ICD-9-CM 314.0, 314.00, 314.01, any position) who meet aspects of the PMCoE measure
Index event … during continuous enrollment period
Anchor Date
Date of ADHD diagnosis at the physician visit
Event … with ADHD (ICD-9-CM 314.0, 314.00, 314.01, any position) who meet aspects of the PMCoE measure
Index event … with ADHD (ICD-9-CM 314.0, 314.00, 314.01, any position) who meet aspects of the PMCoE measure
Index event
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-240-section-2-technical-specifications.pdf
February 21, 2020 - BMI Body mass index for the child is reported to be ≥85th percentile
Event/Diagnosis Child’s parents
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/asc-resource-list.pdf
April 01, 2023 - Staff can use this decision tree when analyzing an
error or adverse event in an organization to help … identify how human factors and systems issues
contributed to the event. … Staff can use this decision tree when
analyzing an error or adverse event in an organization to help … identify how human factors and
systems issues contributed to the event. … Leadership Response to a Sentinel Event: Respectful, Effective Crisis Management
5.
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www.cahps.ahrq.gov/news/events/index.html
November 01, 2022 - Skip to main content
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www.cahps.ahrq.gov/news/blog/ahrqviews/patient-workforce-safety.html
March 01, 2023 - The event was attended by 800 people online and 200 in person—in my view a strong signal of consensus … I was glad for AHRQ to take the lead in organizing the November 14 event.
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0197-technicalspecs.pdf
October 29, 2019 - Event/Diagnosis Imaging studies of the head (CT or MR; Table IMG1) for the evaluation of
atraumatic
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www.cahps.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-3/slides.html
September 01, 2017 - Components
A brief staff gathering, interdisciplinary when possible, that immediately follows a fall event … Convenes within 15 minutes of the fall event. … Led by clinician(s) responsible for patient/resident during the fall event. … Slide 46: Root Cause Analysis
After an injurious fall, collect data to reconstruct the event and
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module3/module3_slides_best-practices.pptx
June 16, 2017 - Components
A brief staff gathering, interdisciplinary when possible, that immediately follows a fall event … Convenes within 15 minutes of the fall event
Led by clinician(s) responsible for patient/resident during … the fall event
Involves the patient/resident whenever possible in the environment where the patient/ … Review
Tool 3N
‹#›
Root Cause Analysis
After an injurious fall, collect data to reconstruct the event
-
www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Reiling.pdf
January 01, 2004 - Unfortunately, a small portion of errors do result in an
“adverse event”—an injury caused by medical … preventable medical death will occur in the range of 3 to 6 per 1,000
admissions and that an adverse event … their infections.22
Moreover, operative and postoperative complications were the number-two
sentinel event … Sentinel event statistics. … Sentinel Event Alert, 28: 2003. http://www.jcaho
.org/about+us/news+letters/sentinel+event+alert/print
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module4/ts2-0ltc_module4_ig_lead.pdf
May 10, 2017 - DISCUSSION:
• What event necessitated the need for the huddle?
– Mrs. … Debriefs can be a short (about 3 minutes or less) team event,
typically initiated and facilitated by … Use of these tools leads to gaining a shared model
or understanding of a situation or event (i.e., … • What event necessitated the need for the huddle? … • Accurate recounting and documentation of key events;
• Analysis of why the event occurred, what worked
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/ehr-reports.pdf
March 01, 2016 - point-prevalence (e.g., population health management) or
incidence-interval (e.g., fee for service event … In
contrast, “interval incidence reports,” more typical of
traditional clinical reporting, uses an event … In contrast, an
interval incidence report uses an event, or
activity, as the unit of analysis. … The look-back period, in this case
12 months, should not be confused with the number of
times an event … An example
would be patients with a 5-year risk of a
cardiovascular event > 7.5% who have a statin
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_1_IDEAL_chklst_508.pdf
January 01, 2010 - patients
and families in discharge planning
Nearly 20 percent of patients experience an adverse
event … Remember that
discharge is not a one-time event but a process
that takes place throughout the hospital … Discharge planning should be an ongoing
process throughout the stay, not a one-time event.
-
www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_1_IDEAL_chklst_508.docx
January 01, 2010 - engaging patients and families in discharge planning
Nearly 20 percent of patients experience an adverse event … Remember that discharge is not a one-time event but a process that takes place throughout the hospital … Discharge planning should be an ongoing process throughout the stay, not a one-time event.
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www.cahps.ahrq.gov/news/newsletters/e-newsletter/818.html
June 01, 2022 - authors of the study, published in JAMA Network Open , cross-referenced Medicare patient-level adverse event … between 2010 and 2019, they found that patients were 13 percent more likely to suffer from an adverse event