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Showing results for "event".

121. Implementation of an Event Reporting and Learning System Leads to Improvements in Patient Safety Culture at UNC Medical Center-Fenton-Wilhelm-Amos (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/4-unc-webcast-fenton-wilhelm-amos.pdf
     August 15, 2019 - Implementation of an Event Reporting and Learning System Leads to Improvements in Patient Safety Culture … 32 U N C H E A L T H C A R E U N C H E A L T H C A R E Perceived barriers to event … reporting software • Double event report submissions by 100% within three years • Increase SOPS scores … in Feedback, Nonpunitive response and Event Reporting by 2021 35 U N C H E A L T H C … Reporting Platform Goal: To develop optimized interface for our event reporting software for event

122. Event Investigation and Analysis Guide: Appendix I | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/capacity/candor/modules/guide4/api.html
     February 01, 2017 - Event Investigation and Analysis Guide: Appendix I Adverse safety event: a deviation from … Causal factor: the suspected or confirmed factors that caused the adverse event. … Often, multiple factors must intersect for an adverse event to reach the patient. … Event review: the overall process of assessing an adverse safety event to determine contributing factors … In-depth event review: the data-gathering phase of an event review, involving conducting interviews,

123. Reporting Patient Safety Events | PSNet
     psnet.ahrq.gov/primer/reporting-patient-safety-events
     March 30, 2022 - Limitations of Event Reporting The limitations of voluntary event reporting systems have been well documented … Failure to receive feedback after reporting an event is a commonly cited barrier to event reporting by … Using Event Reports to Improve Safety A 2016 article contrasted event reporting in health care with … event reporting in other high-risk industries (such as aviation), pointing out that event reporting … analysis, rather than encouraging event reporting for its own sake.

124. Event reporting: the value of a nonpunitive approach. | PSNet
     psnet.ahrq.gov/issue/event-reporting-value-nonpunitive-approach
     June 16, 2011 - Commentary Event reporting: the value of a nonpunitive approach. … Event reporting: the value of a nonpunitive approach. … Event reporting: the value of a nonpunitive approach.

125. Venous thromboembolism after trauma: a never event? | PSNet
     psnet.ahrq.gov/issue/venous-thromboembolism-after-trauma-never-event
     January 12, 2022 - Study Venous thromboembolism after trauma: a never event? … Venous thromboembolism after trauma: a never event?*. … Venous thromboembolism after trauma: a never event?*. … May 13, 2021 Inpatient suicide: preventing a common sentinel event.

126. 2007 Guide to State Adverse Event Reporting Systems. | PSNet
     psnet.ahrq.gov/issue/2007-guide-state-adverse-event-reporting-systems
     November 29, 2009 - Book/Report 2007 Guide to State Adverse Event Reporting Systems. … Citation Text: 2007 Guide to State Adverse Event Reporting Systems. Rosenthal J, Takach M. … Highlighting the large increase in state adverse event reporting systems, this report finds that states … Cite Citation Citation Text: 2007 Guide to State Adverse Event … November 29, 2009 2014 Guide to State Adverse Event Reporting Systems.

127. Bringing the equity lens to patient safety event reporting. | PSNet
     psnet.ahrq.gov/issue/bringing-equity-lens-patient-safety-event-reporting
     September 21, 2009 - Commentary Bringing the equity lens to patient safety event reporting. … Bringing the equity lens to patient safety event reporting. … Safety event reporting from both providers and patients is subject to bias. … Bringing the equity lens to patient safety event reporting.

128. Mapping a Large Patient Safety Database to the 2005 Patient Safety Event Taxonomy (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Clarke_8.pdf
     January 25, 2008 - These event types drive the collection of information germane to a specific event. … as a near-miss or “serious event”; the clinical event type according to the PA-PSRS taxonomy used in … PA-PSRS; the procedure involved; how the event was discovered; the disposition of the event; and the … 75.5 Date of admission 37.9 Type (near-miss or serious event) 37.6 How was event discovered 37.6 … Event type (modified UHC taxonomy) 37.6 Disposition of event 37.6 Procedure error: Procedure 30.0

129. Vaccine Adverse Event Reporting System Reporting Form | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/nursing-home/resources/vaccine-adverse-event-reporting.html
     August 01, 2022 - Nursing Home COVID-19 Action Network Resources Catalog Vaccine Adverse Event … Resources Catalog News Best Practice Summaries Vaccine Adverse Event … Reporting System Reporting Form Resource: Vaccine Adverse Event Reporting System Reporting … August 2022 Page originally created August 2022 Internet Citation: Vaccine Adverse Event … https://www.ahrq.gov/nursing-home/resources/vaccine-adverse-event-reporting.html  

130. A review of the current evidence base for significant event analysis. | PSNet
     psnet.ahrq.gov/issue/review-current-evidence-base-significant-event-analysis
     October 14, 2009 - Review A review of the current evidence base for significant event analysis. … A review of the current evidence base for significant event analysis. … This review assessed research on the benefits and disadvantages of significant event analysis and identified … A review of the current evidence base for significant event analysis. … 2008 A qualitative study of why general practitioners may participate in significant event

131. Development of a measure of patient safety event learning responses. | PSNet
     psnet.ahrq.gov/issue/development-measure-patient-safety-event-learning-responses
     June 28, 2010 - Study Development of a measure of patient safety event learning responses. … Development of a measure of patient safety event learning responses. … The authors defined a set of indicators that evaluate the analysis of the event and the dissemination … of learnings from the event. … Development of a measure of patient safety event learning responses.

132. Social determinants of health and patient safety: an analysis of patient safety event reports related to limited English-proficient patients. | PSNet
     psnet.ahrq.gov/issue/social-determinants-health-and-patient-safety-analysis-patient-safety-event-reports-related
     October 17, 2018 - Social determinants of health and patient safety: an analysis of patient safety event … Social determinants of health and patient safety: an analysis of patient safety event reports related … language barriers   contribute to patient safety events, the authors analyzed near-miss and adverse event … Social determinants of health and patient safety: an analysis of patient safety event reports related … from patient safety event report databases.

133. Leveraging a safety event management system to improve organizational learning and safety culture. | PSNet
     psnet.ahrq.gov/issue/leveraging-safety-event-management-system-improve-organizational-learning-and-safety-culture
     August 01, 2018 - Study Leveraging a safety event management system to improve organizational learning … Leveraging a safety event management system to improve organizational learning and safety culture. … usability , de-centralized event follow-up, and closed-loop communication. … The new SEMS resulted in more event reporting and less staff time spent on each report. … used in daily workflow increases adverse event reporting by physicians.

134. Event-Condition-Action (ECA) rule | CDS Connect
     cds.ahrq.gov/cdsconnect/artifact-type/event-condition-action-eca-rule
     July 05, 2022 - Search All AHRQ Sites Careers Contact Us Español FAQs Email Updates

135. 2014 Guide to State Adverse Event Reporting Systems. | PSNet
     psnet.ahrq.gov/issue/2014-guide-state-adverse-event-reporting-systems
     November 29, 2009 - Book/Report 2014 Guide to State Adverse Event Reporting Systems. … Citation Text: 2014 Guide to State Adverse Event Reporting Systems. … This analysis of 27 state-level reporting programs highlights that while adverse event reporting has … Cite Citation Citation Text: 2014 Guide to State Adverse Event … November 29, 2009 2007 Guide to State Adverse Event Reporting Systems.

136. Automated Adverse Drug Event Detection and Intervention (pdf file)
     digital.ahrq.gov/sites/default/files/docs/activity/automated_adverse_drug_event_detection_and_intervention_2009_update_2.pdf
     January 01, 2009 - Automated Adverse Drug Event Detection and Intervention … Project Title: Automated Adverse Drug Event … Business Goal: Knowledge Creation Summary: The primary purpose of the Automated Adverse Drug Event … Sharing adverse drug event data using business intelligence technology. … AUTOMATED ADVERSE DRUG EVENT DETECTION AND INTERVENTION  3

137. Automated Adverse Drug Event Detection and Intervention | Digital Healthcare Research
     digital.ahrq.gov/ahrq-funded-projects/automated-adverse-drug-event-detection-and-intervention
     January 01, 2023 - Automated Adverse Drug Event Detection and Intervention Project Final Report ( PDF … Every triggering event was investigated in detail within 24 hours to determine whether it represents … Tailoring adverse drug event surveillance to the paediatric inpatient. … Sharing adverse drug event data using business intelligence technology. … Automated Adverse Drug Event Detection and Intervention - Final Report.

138. Communicating After Harm in Healthcare. | PSNet
     psnet.ahrq.gov/issue/guidelines-informing-media-after-adverse-event
     May 08, 2019 - It replaces the Institute's Guidelines for Informing the Media After an Adverse Event first published

139. Reflection on adverse event disclosure in the postsurgical hospital context. | PSNet
     psnet.ahrq.gov/issue/reflection-adverse-event-disclosure-postsurgical-hospital-context
     August 20, 2018 - Commentary Reflection on adverse event disclosure in the postsurgical hospital context … Reflection on adverse event disclosure in the postsurgical hospital context. … Communication between surgeons and patients following an adverse event has received little attention … Reflection on adverse event disclosure in the postsurgical hospital context. … February 17, 2011 Managing the adverse event occurring during elective, ambulatory pediatric

140. Event-Summary-Details-Maximizing-Physician-Buy-In (pdf file)
     www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/event-summary-details-maximizing-physician-buy-in.pdf
     June 16, 2022 - EVENT SUMMARY LEARNING COMMUNITY AFFINITY GROUP | SUMMARY AT-AT-GLANCE | 1 AFFINITY GROUP DETAILS … Format • A moderated panel discussion with three panelists, with additional input from over 70 event … System Director, Cardiac Rehabilitation, Lee Health Resource Link Slides and a recording of the event … EVENT SUMMARY LEARNING COMMUNITY AFFINITY GROUP | SUMMARY AT-AT-GLANCE | 2 OVERALL EVENT THEMES … EVENT SUMMARY LEARNING COMMUNITY AFFINITY GROUP | SUMMARY AT-AT-GLANCE | 3 DISCUSSION HIGHLIGHTS