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  1. www.qualitymeasures.ahrq.gov/teamstepps/officebasedcare/module3/office_comm.html
    September 01, 2015 - † Joint Commission Sentinel Event Data (Root Causes by Event Type). 2004-2012.
  2. www.qualitymeasures.ahrq.gov/npsd/quality-patient-safety/index.html
    August 01, 2020 - By aggregating data submitted in AHRQ’s Common Formats for Event Reporting (a standardized reporting
  3. www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/teamstepps/officebasedcare/ts-obc-online-module1.pptx
    March 01, 2010 - outcomes include: 50% reduction in the Weighted Adverse Outcome Score (WAOS), which describes the adverse event … decrease in the Severity Index, which measures the average severity of each delivery with an adverse event … decrease in the severity index, which measures the average severity of each delivery with an adverse event
  4. www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/NCINQTobaccoUseHelpSpec-Prov.pdf
    August 10, 2016 - Benefit Event/Diagnosis Medical.
  5. www.qualitymeasures.ahrq.gov/news/newsletters/e-newsletter/848.html
    January 01, 2023 - Algorithms’ Impacts on Racial and Ethnic Disparities Registration is open for a two-day virtual event … The online event will explore algorithms’ impacts and approaches to identify and mitigate existing biases
  6. www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/hacreport-2019.pdf
    January 01, 2019 - Measures used to estimate the national HAC rate HAC Type Source Measure Adverse Drug Event MPSMS … Acquired Conditions MPSMS Femoral Artery Puncture for Catheter Angiographic Procedures MPSMS Adverse Event … Associated With Hip Joint Replacements MPSMS Adverse Event Associated With Knee Joint Replacements … for all patients for which the MPSMS data are used, we follow these steps: • Multiply the adverse event … Catheter Angiographic Procedures 22,075 0.74 15,907 0.53 9,118 0.31 15,176 0.51 MPSMS Adverse Event
  7. www.qualitymeasures.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/medicaidmgmt/mm8c.html
    October 01, 2014 - this review include exercise tolerance, recognition of severe disease exacerbation, self-action in the event … that it significantly improved recognition of severe disease exacerbation, use of self-action in the event … measures such as exercise tolerance, recognition of severe disease exacerbation, use of self-action in the event
  8. www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/officebasedcare/handouts/teampercept.pdf
    December 09, 2015 - My supervisor/manager provides opportunities to discuss the team’s performance after an event.
  9. www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/resources/asc-resource_list.pdf
    March 01, 2016 - Surgical Centers Instructional Videos on Surgical Safety Checklist Use Leadership Response to a Sentinel Event … Staff can use this decision tree when analyzing an error or adverse event in an organization to help … identify how human factors and systems issues contributed to the event. … receives urgent requests from organizations seeking help in the aftermath of a serious organizational event … and restore hope” to patients, families, and clinicians who have been affected by an adverse medical event
  10. www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/curriculum/teamstepps-module-2-slides.pptx
    February 28, 2022 - foster process improvement: Brief, informal information exchange and feedback sessions Occur after an event … teamwork skills Designed to improve outcomes: An accurate recounting of key events Analysis of why the event
  11. www.qualitymeasures.ahrq.gov/practiceimprovement/initiatives.html
    September 01, 2019 - Cardiac Rehabilitation Only 20 percent of the nearly one million Americans who experience a qualifying event
  12. www.qualitymeasures.ahrq.gov/cahps/news-and-events/events/index.html
    January 01, 2024 - Skip to main content An official website of the Department of Health and Human Services Careers Contact Us Español FAQs Search all AHRQ sites Search small Search Menu …
  13. www.qualitymeasures.ahrq.gov/teamstepps/readiness/informationitems.html
    April 01, 2016 - Objective information can originate from a variety of sources, including adverse event and near-miss … For continued success, the organization needs to view the culture change as a process rather than an event
  14. www.qualitymeasures.ahrq.gov/sops/webcasts/previous.html
    June 01, 2023 - Tool (December 3, 2020) Understanding SOPS Surveys: A Primer for New Users (February 19, 2020) Event
  15. www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_3_Physician_HO_508.pdf
    January 01, 2010 - patients and families in discharge planning Nearly 20 percent of patients experience an adverse event
  16. www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_3_Physician_HO_508.docx
    January 01, 2010 - engaging patients and families in discharge planning Nearly 20 percent of patients experience an adverse event
  17. www.qualitymeasures.ahrq.gov/workingforquality/events/webinar-introduction-to-the-stakeholder-toolkit.html
    November 01, 2016 - Agenda [Slide 2] Ann Gordon: My name is Ann Gordon and I will be facilitating today's event. … But do know that a copy of the slides from this presentation as well as a transcript of today's event … Wilson before wrapping up today's event? Dr. … Look for an email from us in the coming days directing you to the archive of today's event.
  18. www.qualitymeasures.ahrq.gov/teamstepps/instructor/fundamentals/module3/igcommunication.html
    March 01, 2019 - According to sentinel event data compiled by the Joint Commission between 1995 and 2005, ineffective … Say: A call-out is a tactic used to communicate critical information during an emergent event. … It also benefits a recorder when present during a code or emergent event. … did the call-outs made by the nurse and intern aid the team during this emergent Labor and Delivery event
  19. Fallpxtool0A (doc file)

    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallpxtoolkit/fallpxtool0a.docx
    January 01, 2011 - [footnoteRef:1] In addition, falls with serious trauma have become a “never” event from the standpoint
  20. www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/uti-one-pager.pdf
    September 01, 2022 - Cefdinir, cefpodoxime Fluoroquinolones are not recommended as first-line agents due to the adverse event

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