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Showing results for "event".

21. Sensemaking and Learn from Defects for Perinatal Safety (pdf file)
    www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.pdf
    May 01, 2017 - 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- Slide 13 Sensemaking … The tree is an interpretation of the event.

22. C2 Prioritization Worksheet Example (pdf file)
    www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/c2_pdi_prioritizationworksheetexample.pdf
    June 05, 2016 - Indicators Toolkit Prepared by RAND and UHC for AHRQ Tool C.1 Volume of Cases at Risk Cost of Single Event … E F G H I J K L M N O P Q R List of PDIs Own Rate National Comparator Annual volume of this event … Anticipated average cost for one case with this event The total annual cost of this event to … organization Anticipated cost to investigate/ implement new process is less than annual cost of event … established organizational goals and priorities • Regulatory • Value-based purchasing • Sentinel event

23. AHRQ Pediatric Quality Indicators Prioritization Worksheet (pdf file)
    www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/c1_pdi_prioritizationworksheet.pdf
    June 05, 2016 - Indicators Toolkit Prepared by RAND and UHC for AHRQ Tool C.1 Volume of Cases at Risk Cost of Single Event … E F G H I J K L M N O P Q R List of PDIs Own Rate National Comparator Annual volume of this event … Anticipated average cost for one case with this event The total annual cost of this event to … organization Anticipated cost to investigate/ implement new process is less than annual cost of event … established organizational goals and priorities • Regulatory • Value-based purchasing • Sentinel event

24. Communication and Optimal Resolution (CANDOR) Toolkit | Agency for Healthcare Research and Quality
    www.healthcare411.ahrq.gov/patient-safety/settings/hospital/candor/modules.html
    August 01, 2022 - Organizational Buy-in and Support Module 3: Preparing for Implementation: Gap Analysis Module 4: Event … Reporting, Event Investigation and Analysis Analysis Module 5: Response and Disclosure Module 6: … Generally, the CANDOR process begins with identification of an event that involves harm. … This activates initiation of coordinated post-event processes, as depicted below and described in the … Investigate and analyze an adverse event to learn from it and prevent future adverse events.

25. Sample Disaster Preparedness Letter to Families (doc file)
    www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/nursing-home/resources/letter-emergency-contact.docx
    May 12, 2022 - health, safety, and dignity of your loved one and are committed to protecting our residents in the event … we can contact during an emergency to share our plans for sheltering in place or evacuation in the event … We would discuss this option further with you while we prepare for such an event. … Please complete the information below for our records so we know how best to proceed in the event of

26. Event Investigation and Analysis Guide: Appendix B | Agency for Healthcare Research and Quality
    www.healthcare411.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apb.html
    August 01, 2022 - Patient Safety Resources by Setting Hospital Hospital Resources CANDOR Event … Patient Safety News and Events Education & Training Resources Event … Investigation and Analysis Guide: Appendix B Detailed Review Timeline Event Type: Individuals … Timeline of Event: March 12, 2014 (0900) RN#1 received report from ED on patient Mrs. … Page last reviewed August 2022 Page originally created April 2016 Internet Citation: Event

27. Hospital Survey on Patient Safety (doc file)
    www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.doc
    June 09, 2016 - Instructions This survey asks for your opinions about patient safety issues, medical error, and event … · An “event” is defined as any type of error, mistake, incident, accident, or deviation, regardless … When an event is reported, it feels like the person is being written up, not the problem (1 (2 (3 … No event reports ( d. 6 to 10 event reports ( b. 1 to 2 event reports ( e. 11 to 20 event reports … ( c. 3 to 5 event reports ( f. 21 event reports or more SECTION H: Background Information This

28. Hospital Survey on Patient Safety (pdf file)
    www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.pdf
    December 22, 2017 - • An “event” is defined as any type of error, mistake, incident, accident, or deviation, regardless … When an event is reported, it feels like the person is being written up, not the problem ......... … We are given feedback about changes put into place based on event reports ......................... … No event reports  d. 6 to 10 event reports  b. 1 to 2 event reports  e. 11 to 20 event reports  … c. 3 to 5 event reports  f. 21 event reports or more SECTION H: Background Information This information

29. Hospital Survey on Patient Safety (pdf file)
    www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/resources/hospscanform.pdf
    March 22, 2017 - • An “event” is defined as any type of error, mistake, incident, accident, or deviation, regardless … When an event is reported, it feels like the person is being written up, not the problem ......... … We are given feedback about changes put into place based on event reports ......................... … No event reports  d. 6 to 10 event reports  b. 1 to 2 event reports  e. 11 to 20 event reports  … c. 3 to 5 event reports  f. 21 event reports or more SECTION H: Background Information This information

30. Patient and Family Engagement | Agency for Healthcare Research and Quality
    www.healthcare411.ahrq.gov/hai/cusp/modules/patient-family-engagement/notes.html
    September 01, 2013 - Immediate Response to an Adverse Event 4 Slide 24. … How to Communicate About an Adverse Event 6 Slide 26. … What if an Adverse Event Occurs on the Unit? … event, and the care provided as a result of the event … of emotions when an adverse event occurs.

31. Asthma 1 Measure Calculation Steps (pdf file)
    www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/pqmp/toolkits/flow-diagrams.pdf
    March 11, 2021 - DEC_TOTAL_MEM_LEVEL Identify payer details associated with most recent qualifying event Sum event … DEC_IDENT_CE Concatenate denominator month tables 10) AST1_OUT.DENOMINATOR_RAW_DATA Deduplicate: 1 event … payer/member combos that exist in the denominator Deduplicate so that there is only 1 numerator event … asthma (ie - is in the denominator) 6If a qualified member has no numerator events during a month, the event

32. Strategies to Better Manage Lipids – Statin Pearls
    www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/evidencenow/heart-health/strategies-to-better-manage-lipids.pptx
    November 01, 2016 - Recommendation Grade Adults ages 40-75 years with no symptoms or history of CVD and a calculated 10-year CVD event … dyslipidemia, diabetes, hypertension, or smoking) They have a calculated 10-year risk of a cardiovascular event … of 10% or greater Identification of dyslipidemia and calculation of 10-year CVD event risk requires … Recommendation Grade Adults ages 40-75 years with no symptoms or history of CVD and a 10-year CVD event … statin use may be beneficial for the primary prevention of CVD events in some adults with a 10-year CVD event

33. Patient and Family Engagement for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
    www.healthcare411.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/pf-engagement-fac-guide.html
    July 01, 2023 - Engaging after an adverse event. Engaging in planning and design. … Immediately after an adverse event, care providers: Provide care. … event, and the care provided as a result of the event. … a number of emotions when an adverse event occurs. … Rarely does an adverse event occur as a result of intent.

34. C1 Prioritization Worksheet (xls file)
    www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheet.xlsx
    July 01, 2016 - disagree/low) Barrier Assessment (indicate Yes or No) Volume of Cases at Risk Cost of Single Event … G H I J K L M N O P Q R List of PSIs/IQIs/PDIs Own Rate National Comparator Annual volume of this event … Anticipated average cost for one case with this event The total annual cost of this event to our organization … Anticipated cost to investigate/ implement new process is less than annual cost of event Anticipated … with established organizational goals and priorities • Regulatory • Value-based purchasing • Sentinel event

35. Patient and Family Engagement for Perinatal Safety | Agency for Healthcare Research and Quality
    www.healthcare411.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/pf-engagement-slides.html
    July 01, 2023 - Discuss how to communicate an adverse event to a patient and family members. … Engaging after an adverse event. Engaging in planning and design. … Slide 18: Immediate Response to an Adverse Event 4 Care for the patient. … Document the event in the medical record. … Slide 21: Next Steps in Responding to an Adverse Event 6 Investigation.

36. Module 3: Preparing for Implementation: Gap Analysis | Agency for Healthcare Research and Quality
    www.healthcare411.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/notes.html
    August 01, 2022 - Define a CANDOR event. Develop a measurement strategy. … Event Reporting, Investigation, and Analysis Team—responsible for reviewing the organization’s current … Slide 6 Say: A CANDOR event is defined as an event that involves unexpected harm (physical, … As the culture begins to change, the organization can start to expand the definition of a CANDOR event … and Event Investigation and Analysis.

37. Event Investigation and Analysis Guide: Appendix G | Agency for Healthcare Research and Quality
    www.healthcare411.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apg.html
    August 01, 2022 - Patient Safety Resources by Setting Hospital Hospital Resources CANDOR Event … Patient Safety News and Events Education & Training Resources Event … Page last reviewed August 2022 Page originally created April 2016 Internet Citation: Event

38. AHRQ Quality and Safety Review System (QSRS) | Agency for Healthcare Research and Quality
    www.healthcare411.ahrq.gov/patient-safety/quality-measures/qsrs/index.html
    September 01, 2022 - Overall, the QSRS will generate adverse event rates and trend performance over time. … The QSRS also: Offers an expanded array of adverse event measures, including ones related to opioid … standardized definitions and algorithms, consistent with those used by the AHRQ Common Formats for Event … This approach ensures that an event identified at one institution is the same as one identified elsewhere

39. Event Investigation and Analysis Guide: Appendix A | Agency for Healthcare Research and Quality
    www.healthcare411.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apa.html
    August 01, 2022 - Patient Safety Resources by Setting Hospital Hospital Resources CANDOR Event … Patient Safety News and Events Education & Training Resources Event … Event Summary:   The wrong concentration of potassium (K+) was used in the compounding of TPN. … Page last reviewed August 2022 Page originally created April 2016 Internet Citation: Event

40. Nursing Home Workplace Safety Resource List (pdf file)
    www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursing-home-workplace-safety-resources.pdf
    January 01, 2023 - /resources/patient-safety-topics/sentinel-event/sentinel- event-alert-newsletters/sentinel-event-alert … /sentinel-event-alert-newsletters/sentinel-event-alert-59-physical-and-verbal-violence-against-health-care-workers … https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/sentinel- event-alert-newsletters … /sentinel-event-alert-60-developing-a-reporting-culture-learning-from- close-calls-and-hazardous-condi … /sentinel-event-alert-newsletters/sentinel-event-alert-60-developing-a-reporting-culture-learning-from-close-calls-and-hazardous-condi