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61. Gap Analysis Facilitator's Guide: Appendix B | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/apb.html
    August 01, 2022 - Does the hospital routinely use its REAL data to identify patient safety event disparities and establish … Is an attempt made to disclose within the first 24 hours following an adverse event? … Do staff have the opportunity to participate in event investigations and process improvement initiatives … Has an organized process to assess behavior related to the event been established? … Is supportive care provided to the caregiver within 24 hours of the event?

62. Gap Analysis Facilitator's Guide: Appendix C | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/apc.html
    August 01, 2022 - Does the hospital routinely use its patient REAL data to identify patient safety event disparities and … Is an attempt made to disclose within the first 24 hours following an adverse event?         … Do staff have the opportunity to participate in event investigations and process improvement initiatives … Has an organized process to assess behavior related to the event been established?         … Is supportive care provided to the caregiver within 24 hours of the event?        

63. Facilitator's Notes (continued) | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/teamstepps/simulation/traininggd1.html
    July 01, 2016 - Because the checklists are event-based and the scenarios are scripted in advance, the rater knows when … each event will occur and can direct his or her attention to the targeted responses. … A good rule is that they have a key event every 1 to 2 minutes of scenario time. (2 min.) … Remind participants that event-based methods involve more than just measurement. … Event-based methods involve good training design practices, good scenario design practices, and good

64. VHA's Journey to High Reliability: Advancing Toward Zero Harm and Becoming a Learning Health System
    www.cpsi.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

65. AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Patient and Family Engagement
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/engagement.pptx
    May 01, 2017 - Patient & Family 5 Engagement Strategies Engaging in everyday care Engaging after an adverse event … Safety Program for Perinatal Care Patient & Family 16 Engaging After Adverse Events An adverse event … Prompt, compassionate, and honest communication with the patient and family after an adverse event is … the appropriate parties Communicate with the patient (who, what, when, where, and why) Document the event … in the medical record 18 AHRQ Safety Program for Perinatal Care Patient & Family Adverse Event

66. Data Measures Guide (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/vae/datameasures-guide.pdf
    January 01, 2017 - (5) occur, o 3 have adverse event (9) occur, o 2 have adverse event (18) occur, and o 3 have adverse … event (20) occur. … event (18) occur and 30% of the patient days had adverse event (20) occur Target Accurate documentation … (5) occur, o 3 have adverse event (9) occur, o 2 have adverse event (18) occur, and o 3 have adverse … event (20) occur.

67. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/vae/vae-tool.docx
    January 01, 2017 - Prevention Bundle AHRQ Safety Program for Mechanically Ventilated Patients Ventilator-Associated Event … Unit __________ Use this tool to track your progress in reducing ventilator-associated event

68. Implementing Near-Miss Reporting and Improvement Tracking in Primary Care Practices: Lessons Learned | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/patient-safety/reports/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?

69. Background and Information for Translators of the AHRQ Hospital Survey on Pateint Safety Culture Version 2.0 (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospital/sops-hsops-2-translation-guidelines.pdf
    August 01, 2023 - When an event is reported in this unit, it feels like the person is being written up, not the problem … (negatively worded) • More about this item: When an event is reported, it feels like the person is … In this unit, we are informed about changes that are made based on event reports. … • More about this item: When changes are made in response to patient safety event reports, staff … Hospital management seems interested in patient safety only after an adverse event happens.

70. Module 4: Teamwork and Communication: Facilitator Notes | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module4/mod4-facguide.html
    March 01, 2017 - The Debrief meeting is ideally conducted with all team members that were involved in the event. … Caring for the resident's physical needs after an event is the first step a provider must take. … However, prompt, compassionate, and honest communication following an event is essential. … , the resident's response to the event, and the care provided as a result of the event. … about an adverse event should be compassionate and sensitive.

71. Hospital Survey on Patient Safety Culture Version 2.0 (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/SOPS-Hospital-Survey-2.0-5-26-2021.pdf
    January 01, 2021 - Instructions This survey asks for your opinions about patient safety issues, medical error, and event … • A “patient safety event” is defined as any type of healthcare-related error, mistake, or incident … 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 .......

72. Mod03-Gap-Analysis-Guide (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module3/mod03-gap-analysis-guide.pdf
    April 01, 2016 - Has an organized process to assess behavior related to the event been established? e. … Is supportive care provided to the caregiver within 24 hours of the event? f. … Is an attempt made to disclose within the first 24 hours following an adverse event? … Has an organized process to assess behavior related to the event been established? … Is supportive care provided to the caregiver within 24 hours of the event?

73. Facilitator's Notes (continued, 2) | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/teamstepps/simulation/traininggd2.html
    March 01, 2018 - Simulation Training Course At the end of this training, participants will be able to: Apply the Event-Based … Event Set With Trigger and Distracters   6. … “Event-based approach to training (EBAT).” … simulation-based training in emergency medicine: The simulation modules for assessment of resident targeted event … “Promoting teamwork: An event-based approach to simulation-based teamwork training for emergency medicine

74. Advances in Patient Safety | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/patient-safety/reports/advances/index.html
    July 01, 2022 - Hilborne, Quang-Tuyen Nguyen What Happens After a Patient Safety Event? … Hargarten Mixed Methods Analysis of Medical Error Event Reports: A Report from the ASIPS Collaborative … Glasgow Development of a Computerized Adverse Drug Event (ADE) Monitor in the Outpatient Setting (   … Hickner, Deborah Graham, Michele Johnson Lessons Learned from the Evolution of Mandatory Adverse Event … Hilborne Standardizing Medication Error Event Reporting in the U.S.

75. AHRQ Quality and Safety Review System (QSRS) | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/cpi/about/otherwebsites/qsrs.ahrq.gov/index.html
    March 01, 2021 - Features The QSRS: Offers an expanded array of adverse event measures. … standardized definitions and algorithms, consistent with those used by the AHRQ Common Formats for Event

76. Transitioning to the SOPS™ Hospital Survey Version 2.0: What’s Different and What To Expect, Part II: Appendixes (pdf file)
    www.cpsi.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%

77. Major Study Finds Significant National Patient Safety Improvement | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/news/newsroom/press-releases/significant-patient-safety-improvement.html
    July 01, 2022 - Researchers found significant decreases in in-hospital adverse event rates for heart attack, heart failure … In the observed data for 2010 and 2019, adverse event rates fell 36 percent for heart attack patients … After adjustment, the relative risk of experiencing an adverse event diminished for all five patient

78. Action Planning Worksheets | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/teamstepps/instructor/essentials/implguide2.html
    November 01, 2018 - Adverse event due to a breakdown in team skills (e.g., communications, situation monitoring, mutual support … Staff members are concerned that we could have an adverse event due to breakdowns in team skills.   … Incorporates redundancy and back-up systems to minimize risk of patient harm in event of error or process … Examples include event counts , rates (percentages) , survey scores, and time-to-event occurrences

79. Hospital Survey on Patient Safety Culture Version 2.0: Composites and Items (pdf file)
    www.cpsi.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.

80. The Brighton Collaboration: Creating a Global Standard for Case Definitions (and Guidelines) for Adverse Events Following Immunization (pdf file)
    www.cpsi.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.