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  1. www.healthcare411.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.
  2. www.healthcare411.ahrq.gov/news/events/index.html
    November 01, 2022 - Skip to main content An official website of the Department of Health and Human Services Careers Contact Us Español FAQs Search all AHRQ sites Search small Search Menu …
  3. www.healthcare411.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.
  4. www.healthcare411.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
  5. www.healthcare411.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
  6. www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/patientsafety/2017qdr-patsafchartbook.pdf
    October 01, 2018 - • Hospital patients with an anticoagulant-related adverse drug event due to low-molecular- weight … , with day of device placement being Day 1 and the line also being in place on the date of event or … If a CL or UC was in place for >2 calendar days and then removed, the date of event of the LCBI must … Adverse Drug Events • An adverse drug event (ADE) is an injury—including physical harm, mental harm, … • The three initial targets of the HHS National Action Plan for Adverse Drug Event Prevention are:
  7. www.healthcare411.ahrq.gov/patient-safety/diagnostic-excellence-grants/index.html
    June 01, 2023 - Expand on our preliminary work in ambulatory care and analyze data from two national patient safety event … Integrate the taxonomy into currently deployed event reporting systems.
  8. www.healthcare411.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
  9. www.healthcare411.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
  10. www.healthcare411.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.
  11. www.healthcare411.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.
  12. www.healthcare411.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
  13. www.healthcare411.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/pf-engagement-fac-notes.html
    May 01, 2017 - Communicate with the patient – Providers communicate by sharing relevant facts about an adverse event … Document the event in the medical record – Providers must document in the medical record the facts of … The documentation should include an objective description of the event, the patient’s response to the … event, and the care provided as a result of the event. … PS 105: Patient Safety and Communicating with Patients After an Adverse Event (updated August 15, 2016
  14. www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/CHIPRA0087-NCINQSexualActivityStatusSpec-Pop.pdf
    October 04, 2016 - Event/Diagnosis None. Hybrid Specification Denominator The eligible population.
  15. www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/CHIPRA0087-NCINQSexualActivityStatusSpec-Prov.pdf
    October 04, 2016 - Benefit Medical Event/Diagnosis Primary care visit.
  16. www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-145-materials-ii.pdf
    January 10, 2017 - allowable gap during continuous enrollment period Anchor Date January 1st of the measurement year Event
  17. www.healthcare411.ahrq.gov/teamstepps/instructor/fundamentals/module3/slcommunication.html
    July 01, 2018 - **(JC Sentinel Event Data (Root Causes by Event Type) 2004-2012).
  18. www.healthcare411.ahrq.gov/patient-safety/reports/engage/interventions/medmanage.html
    June 01, 2023 - will also help to identify patient behaviors that may be putting patients at risk for an adverse drug event
  19. www.healthcare411.ahrq.gov/health-literacy/professional-training/lepguide/chapter2.html
    September 01, 2020 - A field for whether a hospital interpreter was present at the time of the adverse event or was used at … A field to document if a hospital interpreter was called and did not show up at the time of the event … nonqualified personnel for interpretation during the hospitalization or at the time of the adverse event … particularly frontline staff and interpreters, on the full spectrum of what constitutes a patient safety event
  20. www.healthcare411.ahrq.gov/teamstepps/instructor/essentials/implguide1.html
    November 01, 2018 - change over the test period, you will need to consider "denominator data" or the number of times the event … calculated by dividing the number of events that did occur by the total number of opportunities for the event … Antibiotic Administration Number of patients admitted to labor & delivery who incurred an adverse event … Another simple data calculation is time-to-event-occurrence , or the elapsed time from a defined starting … point to the occurrence of a specific event.

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