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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/01-ASC-webcast-2023-0509-intro.pdf
January 01, 2023 - Webcast Technical Info
• Audio issues
• Poor Connection
• Use Q&A: For Questions or Other Problems
• Event … events.westat.com/sops
► Download presentation slides and view the agenda and speaker bios
on our event
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-143-section-5a-evidence-table.pdf
January 01, 2014 - GJ,
Study monitoring system that identified “alerts”
that possibly indicated an adverse drug
event … Adverse Drug Event
Detection in Pediatric
Oncology and
Hematology Patients:
Using Medication … Recognizing
hypoglycemia in children
through automated
adverse-event detection. … Automated
adverse event detection
collaborative: electronic
adverse event
identification,
classification … those with no event
(95% CI 1.19 to 1.26).
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/pf-engagement-facilitator-guide.docx
May 01, 2017 - Discuss how to communicate an adverse event to patients and family members. … Immediately after an adverse event, care providers:
Provide care. … Caring for the patient’s physical needs after an event is the first step a provider must take. … event, and the care provided as a result of the event. … Rarely does an adverse event occur as a result of intent.
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/simulation/traininggd-update.pdf
February 01, 2011 - The Simulation Module for Assessment of Resident Targeted Event Responses
(SMARTER) approach is an event-based … All event sets consist of a
trigger—the condition under which the event becomes fully activated or the … (2) Each event set should include only one trigger event to avoid introducing too
many variables and … Explain that each slide can be chunked into two event sets, with one
trigger for each event set. … “Event-based approach to training
(EBAT).”
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/nh-workplace-safety-intro.pdf
January 24, 2023 - Webcast Technical Info
• Audio issues
• Poor Connection
• Use Q&A: For Questions or Other Problems
• Event … events.westat.com/sops
► Download presentation slides and view the agenda and speaker bios on
our event
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www.healthcare411.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/scenarios.html
August 01, 2022 - Contents
Scenario 1: Non-Clinical Situation, Group Project Scenario 2: Disclosure Immediately After Event … Scenario 3: Disclosure After Event Analysis Scenario 4: Disclosure After Event Analysis
Scenario 1 … Return to Contents
Scenario 2: Disclosure Immediately After Event
Mary is a 39-year-old mother … Return to Contents
Scenario 3: Disclosure After Event Analysis
Adam, a 55 year-old male is admitted … Return to Contents
Scenario 4: Disclosure After Event Analysis
Alphonse, a 50 year-old CEO of a
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www.healthcare411.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide6.html
August 01, 2022 - that these tiers of support are provided to caregivers after they have in been involved in an adverse event … YES NO
Adverse Event Investigation Process
Is an adverse event policy in place? … Do you have an event investigation process clearly outlined? … available interventional support strategies for clinicians in the aftermath of an unanticipated clinical event … Providing supportive care following an unanticipated clinical event.
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c2_combo_prioritizationworksheetexample.xlsx
July 01, 2016 - ) Barrier Assessment (indicate Yes or No)
Q3/10-Q2/11 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
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/pf-engagement-facilitator-guide.pdf
May 01, 2017 - • Discuss how to communicate an
adverse event to patients and family
members. … Immediately after
an adverse event, care providers:
• Provide care. … Caring for the patient’s
physical needs after an event is the
first step a provider must take. … event, and
the care provided as a result of the
event. … Rarely does an adverse event occur as a
result of intent.
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www.healthcare411.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?
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www.healthcare411.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?
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/hospwebinar/just-culture-webcast-1-intro.pdf
November 09, 2016 - Frequency of event reporting
– 4. Handoffs & transitions
– 5. … Defining Nonpunitive Response to Error
11
The extent to which staff feel
that their mistakes and event … Response to Error Survey
Items
– Staff feel like their mistakes are held against them.
– When an event
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-230-tech-specs.pdf
July 12, 2019 - Event/Diagnosis An outpatient care visit. … height, weight
percentile, or height percentile alone is not sufficient to qualify as a
numerator event … height, weight percentile, or height percentile alone is not sufficient to qualify
as a numerator event
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www.healthcare411.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
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/pqmp/toolkits/sas-code.pdf
October 31, 2018 - Comments: The age variable used is the age at the time of most recent
qualifying denominator event for … length=$4;
if a then event = 'Inpt'; *Inpatient;
if b then event = 'EOA1'; *Ed/Outpatient Asthma: … event type, and service date to create
unique service events for each member_id. … = ev[i], 1, 0);
end;
run;
* Count event type totals by member;
proc sql;
create table &Mth. … Events #3: Ambulatory (ED or Outpatient) event in which asthma dx codes appear in any position.
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0230-section-6-tables-5-7.pdf
April 25, 2018 - sepsis 15 87% 0.72
Septic shock 15 87% 0.58
Table 6: Inter-Rater Reliability of Assessment of Event … within Specified Time Period
Site
Event
Number of
Records Reviewed
Percent
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-229-section-6a-tables-4-5.pdf
February 09, 2018 - Inter-Rater Reliability of Assessment of Event within Specified Time Period
Site Event Number of Records
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www.healthcare411.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?
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www.healthcare411.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.
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/pqmp/toolkits/technical-specifications.pdf
March 03, 2021 - Event/Diagnosis Children who have evidence of claims sufficient to meet the eligibility
criteria … and many ED visits that
result in hospitalization are not captured in encounter data, a numerator event