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Showing results for "event".

21. Using Simulation in TeamSTEPPS Training: Classroom Slides | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/teamstepps/simulation/simulationslides/simslides.html
    June 01, 2019 - Return to Top   Define Event Sets Event sets are the building blocks of a scenario Event sets … Each event set should not include more than one trigger event . … Event sets can be created by breaking a clinical procedure into chunks . … The event sets or behavior categories can be used to structure discussion. … Rule of thumb: Have a key event every 1 to 2 minutes of scenario time.

22. CommonSpirit Health Expands CANDOR Toolkit Across Entire Health System | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/news/newsroom/case-studies/202104.html
    October 01, 2021 - or potential adverse event, and officials estimate 85 patients were spared the additional harm of not … “It’s all about how to communicate an adverse event or a potential adverse event promptly and candidly … "Our goal is to notify the patient and family within 60 minutes of an event," Pelletreau explained. … When an unexpected event occurs, those situations are tracked by a core management team consisting of … “CANDOR is absolutely the right approach for all involved in an adverse event,” Pelletreau said.

23. Medication Dashboard Data 2023 (xls file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/npsd/Medication_Dashboard_Data_2023.xlsx
    January 01, 2023 - tables include the relative frequency of reports by incorrect action, by the stage of process where the event … Originated Med_5 Stage Event Originated by Extent of Harm Med_6 https://www.ahrq.gov … Med_5 Med_5: Stage Event Originated Stage of Process Percentage Frequency Total Unknown 40.3% 51,641 … 2.7% 3,438 128,016 Storing 1.5% 1,980 128,016 Purchasing 0.2% 252 128,016 Med_6 Med_6: Stage Event … Originated by Extent of Harm Stage Event Originated No Harm Percentage No Harm Frequency Harm Percentage

24. NPSD Data Spotlight - Patient Safety and COVID-19: A Qualitative Analysis of Concerns During the Public Health Emergency (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-ptsafety-and-covid-19.pdf
    November 01, 2021 - event, etc.). … Descriptive Text About the Event Referencing COVID-19 Fall Event COVID-19 precautions cause a delay … Other Event Too many things do. … Details of Event or Unsafe Condition, and Contributing Factor(s) for Event were analyzed during a pilot … Number of Records by the Category(s) Associated with the Event or Unsafe Condition Category of Event

25. Mod5-Disclosure-Checklist (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/mod5-disclosure-checklist.pdf
    April 01, 2016 - ■ Identify the adverse event early in the disclosure. … ■ Explain what is known about why the adverse event occurred; do not speculate. … ■ Tell the patient whether the adverse event was preventable, if known. … event. … ■ Consider ways to involve patients in post-event learning.

26. AHRQ Quality Indicators Prioritization Worksheet Example (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c2_combo_prioritizationworksheetexample.pdf
    June 29, 2016 - Anticipated average cost for one case with this event The total annual cost of this event to … Anticipated average cost for one case with this event The total annual cost of this event to … Anticipated average cost for one case with this event The total annual cost of this event to … Anticipated average cost for one case with this event The total annual cost of this event to … Anticipated average cost for one case with this event The total annual cost of this event to

27. The PSO Privacy Protection Center | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/cpi/about/otherwebsites/psoppc.ahrq.gov/index.html
    September 01, 2018 - The PSOPPC provides technical assistance to PSOs to ensure that patient safety event data is rendered … The Common Formats promote consistent event reporting by all providers and health care organizations … assistance services, such as— Educating PSOs on the format for submitting nonidentifiable patient safety event … Rendering PSO patient safety event data nonidentifiable. … software vendors interested in implementing common definitions and reporting formats for patient safety event

28. TAKEheart Learning Community Webinars | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/takeheart/training/learning-community-webinars/index.html
    December 01, 2022 - Select to view the webinar, slides, and event summary . … Select to view the webinar, slides, and event summary . … Select to view the webinar, slides, and event summary . … Select to view the webinar, slides, and event summary . … Select to view the webinar, slides, and event summary.

29. Learning-From-Antibiotic-Adverse (doc file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/learning-from-antibiotic-adverse.docx
    June 01, 2021 - Antibiotic Use Learning From Antibiotic-Associated Adverse Events An antibiotic-associated adverse event … is any event or situation that you would not want to happen again because it either caused your patient … We use a simple four-step approach with the goal of turning a problem, near-miss, or adverse event into … Identify the antibiotic-associated adverse event. (What happened?) Step 2. … Identify the antibiotic-associated adverse event. (What happened?) 2.

30. Affinity-Details-Improving-Support-Women (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/affinity-details-improving-support-women.pdf
    May 01, 2021 - EVENT SUMMARY LEARNING COMMUNITY AFFINITY GROUP | SUMMARY AT-AT-GLANCE | 1 AFFINITY GROUP DETAILS … EVENT SUMMARY LEARNING COMMUNITY AFFINITY GROUP | SUMMARY AT-AT-GLANCE | 2 OVERALL EVENT THEMES … Lack of cardiologist referrals and logistical challenges were also identified by event participants … Additional Details Event slides and a recording of the event provide additional details that complement … The event slides and recording are available online at: TAKEheart.ahrq.gov

31. Development and Usability Testing of the Agency for Healthcare Research and Quality Common Formats to Capture Diagnostic Safety Events (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/topics/development-and-usability-testing-common-formats.pdf
    January 01, 2022 - Agency for Healthcare Research and Quality (AHRQ) began the de- velopment of the Common Formats for Event … Results: Estimated completion time was 30 to 90 minutes per event. … The CFER-DS also offers a definition of a diagnostic safety event using concepts pro- posed in 2 prior … Participants were asked to complete the CFER-DS to simulate event reporting for 5 cases of diagnostic … DISCUSSION Standards for diagnostic safety event reporting are necessary to advance national-level

32. Blood Dashboard Data (xls file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/npsd/Blood_Dashboard_Data_2023.xlsx
    January 01, 2023 - Originated Blood_3 Stage of the Process When Blood or Blood Product Event Originated by Extent … Blood_3 Blood_4: Stage of the Process When Blood or Blood Product Event Originated Process When Blood … or Blood Product Event Originated Percentage Frequency Total Post-transfusion or administration 13.3% … Blood_4 Blood_5: Stage of the Process When Blood or Blood Product Event Originated by Extent of Harm … Stage of Process When Blood or Blood Product Event Originated No Harm Percentage No Harm Frequency

33. Sensemaking and Learn From Defects for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-fac-guide.html
    July 01, 2023 - 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-miss event. … An antecedent describes the preceding event, condition, or cause. … The tree is an interpretation of the event.

34. Proactive Risk Assessment of Surgical Site Infections in Ambulatory Surgery Centers (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/stpra/stpra.pdf
    March 01, 2012 - ) 1 0.000103 Event 173 (0.9) Event 142 (0.3) Event 450 (0.293) Event 642 (0.2) Event 182 (0.2) Event … 173 (0.9) Event 142 (0.3) Event 450 (0.293) Event 642 (0.2) Event 30 (0.125) Event 543 (0.0325) Staff … 173 (0.9) Event 450 (0.293) Event 642 (0.2) Event 182 (0.2) Event 659 (0.18) Event 543 (0.0325) Staff … 173 (0.9) Event 450 (0.293) Event 642 (0.2) Event 182 (0.2) Event 138 (0.15) Event 543 (0.0325) Staff … Event 30 Gate 239 Event 142 Event 659 Event 138 25% reduction in noncompliance Event 30 Fail to

35. Event Investigation and Analysis Guide: Appendix F | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apf.html
    August 01, 2022 - Patient Safety Resources by Setting Hospital Hospital Resources CANDOR Event … Patient Safety News and Events Education & Training Resources Event … name), we would like you to participate in our upcoming solutions meeting related to (describe safety event … is essential to develop effective solutions to the contributing and causal factors found during our event … Page last reviewed August 2022 Page originally created April 2016 Internet Citation: Event

36. AHRQ Hospital Survey on Patient Safety Culture: Items and Dimensions (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hsops-items-composites.pdf
    February 16, 2021 - Hospital management seems interested in patient safety only after an adverse event happens. … We are given feedback about changes put into place based on event reports. C3. … Number of Events Reported (No event reports, 1 to 2 event reports, 3 to 5 event report, 6 to 10 event … reports, 11 to 20 event reports, 21 event reports or more) G1. … In the past 12 months, how many event reports have you filled out and submitted?

37. Survey on Patient Safety (facility version) (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.pdf
    November 18, 2019 - 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 .......... … 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

38. Survey on Patient Safety (facility version) (doc file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.doc
    November 15, 2019 - Safety Instructions This survey asks for your opinions about patient safety issues, medical error, and event … to answer a question, or if a question does not apply to you, you may leave your answer blank. · An “event … 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

39. Prioritization Worksheet (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/c1_pdi_prioritizationworksheetinstructions.pdf
    June 05, 2016 - Column F, “Cost of Single Event,” indicates the average cost to your organization of one event. … both costs and risk of the adverse event (e.g., concurrent cancer diagnosis). … Ideally, if your data permit, consider only costs that occur after the adverse event occurred. … Has your organization recently experienced negative press regarding an event? … What would this look like in the community if you had an event in your organization?

40. Workplace Safety Resource List (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/workplace-safety/workplace_safety_resource_list.pdf
    October 01, 2021 - /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 … /resources/patient-safety-topics/sentinel-event/sentinel-event-alert-newsletters/sentinel-event-alert … https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/sentinel- event-alert-newsletters