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www.healthcare411.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 .......
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www.healthcare411.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?
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www.healthcare411.ahrq.gov/health-literacy/professional-training/lepguide/chapter1.html
September 01, 2020 - Adverse event*:
Any injury caused by medical care. … Identifying something as an adverse event does not imply "error," "negligence," or poor quality care. … Near miss/close call * :
An event or situation that did not produce patient injury, but only because … Never event ** :
The term "never event" refers to a particularly shocking medical error (such as wrong-site … The one hospital that stratified their adverse event data by language found clusters of adverse events
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www.healthcare411.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
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www.healthcare411.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%
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www.healthcare411.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
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www.healthcare411.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
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www.healthcare411.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.
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-0232-technicalspecs.pdf
February 04, 2020 - Event/Diagnosis An outpatient care visit and BMI ≥85th percentile. … Reporting of systolic and/or diastolic blood pressure only is not sufficient to qualify as a numerator
event
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-136-section-2-tech-specs.pdf
January 01, 2012 - Other qualifying events after the fifth birthday at time of event:
One or more prior ambulatory visits … Exclude those children who have previously had an event
(include only the first hospitalization or ED … Qualifying events after the fifth birthday at time of event:
1) One or more prior ambulatory visits … were continuously
enrolled for at least 6 continuous months before the month in
which the qualifying event … Use the first such event for
each child when assessing each numerator.
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/topics/public-notes-meeting-summary-031121.pdf
July 22, 2021 - IHS • Enhanced Adverse Event Reporting Capabilities: IHS Safety
Tracking and Response (I-STAR) system … Future goal is to align the platform with AHRQ’s Common Formats
for Event Reporting.
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www.healthcare411.ahrq.gov/talkingquality/translate/scores/scoring.html
June 01, 2016 - The choice of reporting only “yes” or “no” answers can be tricky if your measure captures a negative event … Do you want to tell people how often this event happened or how often it did not happen? … Experience indicates that in this case, saying how often a patient safety event did happen will be
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-88-measure-1-section-2-attachment-6.pdf
January 17, 2017 - during continuous enrollment period
Anchor Date
Date of ADHD diagnosis at the physician visit
Event … patients, identify all assessment services (see Table 2) with an ADHD diagnosis
code at the anchor event
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/20160315/susan-edgman-levitan-intro-slides.pdf
March 15, 2016 - Ask a Question
6 www.cahps.ahrq.gov
Accessing Presentations
7 www.cahps.ahrq.gov
Accessing Event … To Ask a Question
Accessing Presentations
Accessing Event Materials
CAHPS Ambulatory Care Improvement
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www.healthcare411.ahrq.gov/teamstepps/officebasedcare/impworkbook.html
December 01, 2015 - □ Adverse event due to a breakdown in team skills (e.g., communications, situation monitoring, mutual … (es) due to breakdowns in team skills
□ Staff members are concerned that we could have an adverse event … □ Incorporates redundancy and backup systems to minimize risk of patient harm in event of error or … Examples include event counts, rates (percentages), survey scores, and time-to-event occurrences .
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/staff-safety-assessment.docx
June 01, 2021 - Category
Unit
Please describe how you think the next resident at your facility will be harmed by an event
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www.healthcare411.ahrq.gov/patient-safety/reports/liability/silence.html
August 01, 2017 - Doing a thorough event investigation and analysis, or root cause analysis, is an important step in the … hour-care provided while the patient is in the medical setting. 4 Third, taking responsibility for the event … adverse events, continuous communication with patients and families throughout the disclosure process, event … Disclosure is not an event, it is a process, and it does not end until the patient or family says it
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www.healthcare411.ahrq.gov/hai/tools/mvp/vae.html
December 01, 2017 - Tools To Support Monitoring VAEs and Outcome Measures
Ventilator-Associated Event Data Collection Tool … - HTML Version of Slide Presentation ; Facilitator Guide - Word , 3 MB)
Ventilator-Associated Event
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-webinar-jan-2017-shaller-intro.pdf
January 01, 2017 - Ask a Question
9
www.ahrq.gov/cahps
Accessing Presentations
10
www.ahrq.gov/cahps
Accessing Event … To Ask a Question
Accessing Presentations
Accessing Event Materials
First Polling Question
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www.healthcare411.ahrq.gov/teamstepps-program/curriculum/team/tools/debrief.html
December 01, 2023 - Analysis of why the event occurred, what worked, and what did not work. … Debriefs can be a short (about 3 minutes or less) team event, typically initiated and facilitated by