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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
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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
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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
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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
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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.
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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
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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
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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?
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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
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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
-
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
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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
-
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
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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
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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
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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
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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.
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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.
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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
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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.