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  1. www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/affinity-group-operational-adjustments-in-person-cr.pdf
    February 01, 2020 - information and links to COVID-19 resources (https://takeheart.ahrq.gov/coronavirus) Today’s Event … Resources Mentioned in Today’s Event 14 For definitive guidance regarding what you can disclose to … discussions of key topics with peers at: https://takeheart.ahrq.gov/collaboration  Today’s slides and an event … summary will be emailed to event participants and posted online at: https://takeheart.ahrq.gov 
  2. www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/leveraging-data-slides.pdf
    April 01, 2021 - information and links to COVID-19 resources (https://takeheart.ahrq.gov/coronavirus) Today’s Event … TAKEheart participants should submit a completed plan by Dec. 18 Resources Mentioned in Today’s Event … discussions of key topics with peers at: https://takeheart.ahrq.gov/collaboration  Today’s slides and an event … summary will be emailed to event participants and posted online at: https://takeheart.ahrq.gov  Please
  3. www.qualitymeasures.ahrq.gov/research/findings/final-reports/stpra/stprasumm.html
    April 01, 2013 - We assigned probabilities to each basic event in the fault tree, using information available from the … This process resulted in a probability of occurrence of the top-level event, along with the major risk … Intervention Next, we examined the events from the ST-PRA model ranked in order of criticality, finding that Event … 642 [Fail to protect the patient effectively] ranked as the most critical unique event, with the highest … Based on this finding, we propose an intervention aimed at Event 642 [Fail to protect patient effectively
  4. www.qualitymeasures.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
  5. www.qualitymeasures.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.
  6. www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/practical-methods-care-coordination-slides.pdf
    December 14, 2022 - the chat box, please list any questions or comments you have for the panelists. 13 Next Steps  Event … interest, and any resources or strategies you’re using that are working well  Feedback on Today’s Event … : Please respond to the polling questions before you exit today’s event 14
  7. www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cusp-icu-slides.pptx
    April 01, 2022 - Program for ICUs: Preventing CLABSI and CAUTI Applying CUSP ׀ 10 10 Where To Find Defects8,9 Adverse event … Analysis To identify root causes of an infection, opportunities for improvement Tools/techniques CLABSI Event … Report template CAUTI Event Report template 5 Whys Staff Safety Assessment Brainstorming To generate … Event Report Tools The event report tools have the following domains: Demographics CLABSI/CAUTI information … ICU Video – Creating Team Buy-In To Work Toward Zero Preventable Infections in ICUs CLABSI and CAUTI Event
  8. www.qualitymeasures.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?        
  9. www.qualitymeasures.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
  10. www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/enhancing-care-heart-failure-patients.pdf
    February 13, 2023 - u n g , M S N , A N P - B C N o v e m b e r 2 , 2 0 2 1 Welcome and Background for Today’s Event … see your question Try the chat function now by sharing one thing you hope to learn during today’s event … discussions of key topics with peers at: https://takeheart.ahrq.gov/collaboration  Today’s slides and an event … summary will be emailed to event participants and posted online at: https://takeheart.ahrq.gov  Please
  11. www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/one-pager-aspiration-pneumonia.docx
    June 01, 2021 - is a bacterial pneumonia that may develop in some residents (20–25%) 48–72 hours after an aspiration event … Prevention—speech and swallow evaluation Antibiotics Respiratory support Treatment · Aspiration event … · Aspiration event and the resident becomes unstable · The following signs are indicative of unstable
  12. www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/emerging-strategies-slides.pdf
    August 12, 2020 - takeheart.ahrq.gov/coronavirus) 2 Today’s Event … Resources Mentioned in Today’s Event … discussions of key topics with peers at: https://takeheart.ahrq.gov/collaboration  Today’s slides and an event … summary will be emailed to event participants and posted online at: https://takeheart.ahrq.gov 
  13. www.qualitymeasures.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
  14. www.qualitymeasures.ahrq.gov/patient-safety/resources/consumer-exp/systems/index.html
    October 01, 2014 - Designing Consumer Reporting Systems for Patient Safety Events Current patient safety event … Current Reporting Systems Current patient safety event reporting systems are aimed at obtaining information … Research to Create Patient Safety Event Reporting Systems for Consumers To develop recommendations … What is the most effective operational approach for consumers to report patient safety event information
  15. www.qualitymeasures.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
  16. www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/implementation-guide.pdf
    April 01, 2022 - for Preventing CLABSI and CAUTI in the ICU Setting CLABSI and CAUTI Learning Tools: CLABSI/CAUTI Event … The event reporting tools support a thorough review of a CLABSI or CAUTI to support the team in identifying … The event reporting tools have a comprehensive list of questions specific to CLABSI and CAUTI that can … CLABSI Event Reporting Tool CAUTI Event Reporting Tool The Learning From Defects tools support a … http://www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cauti-event-reporting.docx
  17. www.qualitymeasures.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.
  18. Facilitator-Notes (doc file)

    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module4/facilitator-notes.docx
    March 01, 2017 - The Debrief meeting is ideally conducted with all team members that were involved in the event. … SLIDE 27 SAY: Communication following an adverse event can been especially challenging. … 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. … occurs, so communication about an adverse event should be compassionate and sensitive.
  19. www.qualitymeasures.ahrq.gov/npsd/data/dashboard/medication-supplement.html
    September 01, 2023 - includes information organized by medication events at a glance, including description of substance event … , stage event originated, and type of substance involved for incidents, near misses, and unsafe conditions
  20. www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/program-dev-slides.pptx
    June 01, 2021 - for 8 days without monitoring. 7 Developing a Program 7 Reviewing the Events Clinical Event … Developing a Program 9 10 Identifying the Problems—2 Clinical Event Son notes resident has dark … Developing a Program 10 11 Identifying the Problems—3 Clinical Event Son notes resident has dark … Developing a Program 11 12 Identifying the Problems—4 Clinical Event Son notes resident has … Developing a Program 12 Clinical Event Son notes resident has dark urine, with a foul odor.

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