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healthcare411.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes6.html
August 01, 2022 - (s) involved in the event. … The reliving of the event is also known as a "tripping" or "triggering" event and can occur when the … The event might produce feelings of internal inadequacy, either because the event occurred or because … the post-event period. … , not just the details of the event.
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cahps.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes6.html
August 01, 2022 - (s) involved in the event. … The reliving of the event is also known as a "tripping" or "triggering" event and can occur when the … The event might produce feelings of internal inadequacy, either because the event occurred or because … the post-event period. … , not just the details of the event.
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monahrq.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes6.html
August 01, 2022 - (s) involved in the event. … The reliving of the event is also known as a "tripping" or "triggering" event and can occur when the … The event might produce feelings of internal inadequacy, either because the event occurred or because … the post-event period. … , not just the details of the event.
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preventiveservices.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes6.html
August 01, 2022 - (s) involved in the event. … The reliving of the event is also known as a "tripping" or "triggering" event and can occur when the … The event might produce feelings of internal inadequacy, either because the event occurred or because … the post-event period. … , not just the details of the event.
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes6.html
August 01, 2022 - (s) involved in the event. … The reliving of the event is also known as a "tripping" or "triggering" event and can occur when the … The event might produce feelings of internal inadequacy, either because the event occurred or because … the post-event period. … , not just the details of the event.
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/checklist5.html
August 01, 2022 - 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.
… Explain your role in the event to the patient/family; avoid blaming others or "the system" for the event … Consider ways to involve patients in post-event learning.
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www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2020.pdf
January 01, 2020 - TYPE, category of event (EVENT TYPE), and INITIAL
REPORT DATE. … concern (CATEGORY ASSOCIATED WITH
EVENT OR UNSAFE CONDITION [EVENT TYPE]) as a percentage of all EVENT … (Event Types)
Report Type by Event Type
Report Type by Event Type
Report Type by Event Type (Data … Extent of Harm by Event Type (Data Table)
Event Type by Extent of Harm
Event Type by Extent of Harm … Originated
Stage Event Originiated
Stage Event Originated by Extent of Harm
Stage Event Originiated
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www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-medication-chartbook-2024.pdf
January 01, 2024 - For
example, DE288: “Which of the following best characterizes the event?” … Among
Medication or Other Substance event reports with complete event descriptions, the majority … of whether the event
resulted in harm to the patient. … question: “What factor(s) contributed to the event?” … FACTOR(S) FOR EVENT were
excluded from analyses
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psnet.ahrq.gov/issue/african-american-covid-19-mortality-sentinel-event
November 16, 2022 - Emerging Classic
African American COVID-19 mortality: a sentinel event … African American COVID-19 mortality: a sentinel event. … African American COVID-19 mortality: a sentinel event.
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psnet.ahrq.gov/issue/improving-adverse-drug-event-reporting-healthcare-professionals
April 12, 2019 - Review
Improving adverse drug event reporting by healthcare professionals. … Improving adverse drug event reporting by healthcare professionals. … Improving adverse drug event reporting by healthcare professionals.
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psnet.ahrq.gov/issue/challenges-and-opportunities-patient-safety-event-reporting
June 23, 2021 - Commentary
Challenges and opportunities of patient safety event reporting. … Challenges and opportunities of patient safety event reporting. … Challenges and opportunities of patient safety event reporting. … 23, 2017
A human factors and survey methodology-based design of a web-based adverse event
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psnet.ahrq.gov/issue/avoid-punitive-approach-your-safety-event-reporting
October 23, 2019 - Newspaper/Magazine Article
Avoid punitive approach to your safety event reporting … ,
Citation Text:
Avoid punitive approach to your safety event reporting, Cheney C. … Cite
Citation
Citation Text:
Avoid punitive approach to your safety event … December 23, 2020
A narrative review of strategies to increase patient safety event reporting … September 16, 2020
When safety event reporting is seen as punitive: "I've been PSN-ed
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psnet.ahrq.gov/issue/nurses-perspective-serious-adverse-drug-event
August 29, 2007 - Commentary
Nurses' perspective on a serious adverse drug event. … Nurses' perspective on a serious adverse drug event. Am J Health Syst Pharm. 1999;56(9):904-7. … Nurses' perspective on a serious adverse drug event. Am J Health Syst Pharm. 1999;56(9):904-7. … Reporting of Clinical Adverse Events Scale: a measure of doctor and nurse attitudes to adverse event … Intervention of pharmacist included in multidisciplinary team to reduce adverse drug event
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psnet.ahrq.gov/issue/health-implications-apologizing-after-adverse-event
October 05, 2015 - Commentary
The health implications of apologizing after an adverse event. … The health implications of apologizing after an adverse event. … The health implications of apologizing after an adverse event. … Related Resources From the Same Author(s)
Apologies following an adverse medical event
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www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2019.pdf
January 01, 2019 - Event-specific Reports
The Common Formats include event-specific modules pertaining to nine patient … (EVENT ID); and the REPORT TYPE, category of event (EVENT TYPE), and INITIAL
REPORT DATE. … of different EVENT TYPES. … concern (CATEGORY ASSOCIATED WITH
EVENT OR UNSAFE CONDITION [EVENT TYPE]) as a percentage of all EVENT … Types)
Report Type by Event Type
Extent of Harm by Event Type
Event Type by Extent of Harm
Extent
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www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2021.pdf
January 01, 2021 - TYPE, category of event (EVENT TYPE), and INITIAL
REPORT DATE. … concern (CATEGORY ASSOCIATED WITH
EVENT OR UNSAFE CONDITION [EVENT TYPE]) as a percentage of all EVENT … (Event Types)
Report Type by Event Type
Report Type by Event Type
Report Type by Event Type (Data … Extent of Harm by Event Type (Data Table)
Event Type by Extent of Harm
Event Type by Extent of Harm … Originated
Stage Event Originiated
Stage Event Originated by Extent of Harm
Stage Event Originiated
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/module1-overview.pptx
May 19, 2016 - Unsafe Condition
Near Miss
No Harm Event
CANDOR
Event
Actual harm to patient
Potential patient harm … A CANDOR event is an event that involves unexpected patient harm. … cause of a harm event. … the event. … of a CANDOR Event.
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes7.html
August 01, 2022 - financial settlement, but might not always lead to resolution of all issues related to the adverse event … However, litigation is not always a patient’s or family’s first instinct after an adverse event, so it … Resolution addresses the needs and concerns of patients after an adverse event. … Patients want to know what will be done to prevent the event from happening again. … Potential future injuries that may result from the adverse event.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Schade_63.pdf
January 01, 2007 - Voluntary Adverse Event Reporting in Rural Hospitals
Voluntary Adverse Event Reporting in Rural Hospitals … The final list of event categories with definitions resulted from combination of similar
event types … Event categories with <2 percent frequency are not
shown. … Event Rates in Participating Hospitals
Figure 1. … was not proportional to the risk of an event.
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www.ahrq.gov/patient-safety/settings/hospital/candor/grand-rounds.html
August 01, 2022 - actually compounded the injury from the event itself. … An event report is completed, which will trigger analysis of the event. … The Investigation: to determine how the event occurred, and how to mitigate that event or even prevent … analysis of an adverse event. … Host event analysis training using tools from CANDOR.