-
pcmh.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.
-
psnet.ahrq.gov/node/60749/psn-pdf
August 05, 2020 - Classification of opioid dependence, abuse, or overdose
in opioid-naive patients as a "Never Event". … Classification of opioid dependence, abuse, or overdose in opioid-naive patients as a
"Never Event". … psnet.ahrq.gov/issue/classification-opioid-dependence-abuse-or-overdose-opioid-naive-patients-
never-event … psnet.ahrq.gov/issue/classification-opioid-dependence-abuse-or-overdose-opioid-naive-patients-never-event … psnet.ahrq.gov/issue/classification-opioid-dependence-abuse-or-overdose-opioid-naive-patients-never-event
-
pbrn.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes7.html
August 01, 2022 - 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. … Some organizations choose to involve patients/families in some manner in the event analysis process. … Potential future injuries that may result from the adverse event.
-
pcmh.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes7.html
August 01, 2022 - 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. … Some organizations choose to involve patients/families in some manner in the event analysis process. … Potential future injuries that may result from the adverse event.
-
www.qualitymeasures.ahrq.gov/research/findings/final-reports/stpra/stpraexh9.html
April 01, 2018 - Event 142 (0.3)
Staff not well-trained in infection control
Event 450 (0.293)
Obese, … Event 182 (0.2)
Fail to administer indicated antibiotics
Event 543 (0.0325)
SSI risk for … during home care
Event 433 (0.05)
Patient has organism at postoperative visit
Event 543 … Event 30 (0.125)
Fail to prepare skin appropriately
Event 543 (0.0325)
SSI risk for obese … Event 450 (0.293)
Obese, but not diabetic, patient (30Event 642 (0.2)
Fail
-
ce.effectivehealthcare.ahrq.gov/research/findings/final-reports/stpra/stpraexh9.html
April 01, 2018 - Event 142 (0.3)
Staff not well-trained in infection control
Event 450 (0.293)
Obese, … Event 182 (0.2)
Fail to administer indicated antibiotics
Event 543 (0.0325)
SSI risk for … during home care
Event 433 (0.05)
Patient has organism at postoperative visit
Event 543 … Event 30 (0.125)
Fail to prepare skin appropriately
Event 543 (0.0325)
SSI risk for obese … Event 450 (0.293)
Obese, but not diabetic, patient (30Event 642 (0.2)
Fail
-
psnet.ahrq.gov/node/42822/psn-pdf
December 18, 2013 - Automated adverse event detection collaborative:
electronic adverse event identification, classification … Automated adverse event detection collaborative: electronic
adverse event identification, classification … https://psnet.ahrq.gov/issue/automated-adverse-event-detection-collaborative-electronic-adverse-event … https://psnet.ahrq.gov/issue/automated-adverse-event-detection-collaborative-electronic-adverse-event-identification … https://psnet.ahrq.gov/issue/automated-adverse-event-detection-collaborative-electronic-adverse-event-identification
-
psnet.ahrq.gov/node/43192/psn-pdf
December 15, 2014 - Using estimated true safety event rates versus flagged
safety event rates: does it change hospital profiling … Using estimated true safety event rates versus flagged safety event
rates: does it change hospital profiling … https://psnet.ahrq.gov/issue/using-estimated-true-safety-event-rates-versus-flagged-safety-event-rates … https://psnet.ahrq.gov/issue/using-estimated-true-safety-event-rates-versus-flagged-safety-event-rates-does-it-change … https://psnet.ahrq.gov/issue/using-estimated-true-safety-event-rates-versus-flagged-safety-event-rates-does-it-change
-
staging-meps.ahrq.gov/survey_comp/overall_p20.shtml
Person
LOOP_02 for each PERSON on RU-Members-Roster WHERE {PERSON continues to have an unprocessed event … }
BEGINLOOP Ask Event-Driver (ED) Section [including
Context: PERSON-EVENT LOOP_03 for each … PERSON-EVENT on Person’s-Medical-Events-Roster WHERE {event remains to be processed} BEGINLOOP If … {event-type is hospital-stay} Ask Hospital-Stay (HS) Section including Charge/Payment (CP) and Flat … (OP) Section including Charge/Payment (CP) and Flat Fee (FF) Sections endif If {event-type is
-
staging-meps.ahrq.gov/survey_comp/overall_p14.shtml
endif
Ask Calendar (CA) Section and Summary of Health Care Events
Ask Provider-Probes (PP) , Event … Person
LOOP_02 for each PERSON on RU-Members-Roster WHERE {PERSON continues to have an unprocessed event … }
BEGINLOOP
Ask Event-Driver (ED) Section [including
Context: PERSON-EVENT
LOOP_03 for … each PERSON-EVENT on Persons-Medical-Events-Roster WHERE {event remains to be processed}}
BEGINLOOP … If {event-type is hospital-stay}
Ask Hospital-Stay (HS) Section including
Charge/Payment
-
staging-meps.ahrq.gov/survey_comp/overall_p15.shtml
endif
Ask Calendar (CA) Section and Summary of Health Care Events
Ask Provider-Probes (PP) , Event … Person
LOOP_02 for each PERSON on RU-Members-Roster WHERE {PERSON continues to have an unprocessed event … }
BEGINLOOP
Ask Event-Driver (ED) Section [including…
Context: PERSON-EVENT
LOOP_03 for … each PERSON-EVENT on Person’s-Medical-Events-Roster WHERE {event remains to be processed}
BEGINLOOP … If {event-type is hospital-stay}
Ask Hospital-Stay (HS) Section including
Charge/Payment
-
meps.ahrq.gov/survey_comp/overall_p13.shtml
August 01, 2009 - endif
Ask Calendar (CA) Section and Summary of Health Care Events
Ask Provider-Probes (PP) , Event … Person
LOOP_02 for each PERSON on RU-Members-Roster WHERE {PERSON continues to have an unprocessed event … }
BEGINLOOP
Ask Event-Driver (ED) Section [including
Context: PERSON-EVENT
LOOP_03 for … each PERSON-EVENT on Persons-Medical-Events-Roster WHERE {event remains to be processed}
BEGINLOOP … If {event-type is hospital-stay}
Ask Hospital-Stay (HS) Section including Charge/Payment
-
meps.ahrq.gov/survey_comp/overall_p14.shtml
September 01, 2010 - endif
Ask Calendar (CA) Section and Summary of Health Care Events
Ask Provider-Probes (PP) , Event … Person
LOOP_02 for each PERSON on RU-Members-Roster WHERE {PERSON continues to have an unprocessed event … }
BEGINLOOP
Ask Event-Driver (ED) Section [including
Context: PERSON-EVENT
LOOP_03 for … each PERSON-EVENT on Persons-Medical-Events-Roster WHERE {event remains to be processed}}
BEGINLOOP … If {event-type is hospital-stay}
Ask Hospital-Stay (HS) Section including
Charge/Payment
-
meps.ahrq.gov/survey_comp/overall_p15.shtml
October 01, 2011 - endif
Ask Calendar (CA) Section and Summary of Health Care Events
Ask Provider-Probes (PP) , Event … Person
LOOP_02 for each PERSON on RU-Members-Roster WHERE {PERSON continues to have an unprocessed event … }
BEGINLOOP
Ask Event-Driver (ED) Section [including…
Context: PERSON-EVENT
LOOP_03 for … each PERSON-EVENT on Person’s-Medical-Events-Roster WHERE {event remains to be processed}
BEGINLOOP … If {event-type is hospital-stay}
Ask Hospital-Stay (HS) Section including
Charge/Payment
-
meps.ahrq.gov/survey_comp/overall_p16.shtml
November 01, 2012 - endif
Ask Calendar (CA) Section and Summary of Health Care Events
Ask Provider-Probes (PP) , Event … }
BEGINLOOP
Ask Event-Driver (ED) Section [including... … Context: PERSON-EVENT
LOOP_03 for each PERSON-EVENT on Persons-Medical-Events-Roster WHERE {event … remains to be processed}
BEGINLOOP
If {event-type is hospital-stay}
Ask Hospital-Stay (HS … ) Section including Charge/Payment (CP) and Flat Fee (FF) Sections
endif
If {event-type
-
meps.ahrq.gov/survey_comp/overall_p17.shtml
December 01, 2013 - Ask Calendar (CA) Section and Summary of Health Care Events
Ask Provider-Probes (PP) , Event … }
BEGINLOOP
Ask Event-Driver (ED) Section [including
Context: PERSON-EVENT
LOOP_03 for each … PERSON-EVENT on Person’s-Medical-Events-Roster WHERE {event remains to be processed}
BEGINLOOP
If … {event-type is hospital-stay}
Ask Hospital-Stay (HS) Section including Charge/Payment (CP) and … including Charge/Payment (CP) and Flat Fee (FF) Sections
endif
If {event-type is outpatient}
-
meps.ahrq.gov/survey_comp/overall_p18.shtml
Person
LOOP_02 for each PERSON on RU-Members-Roster WHERE {PERSON continues to have an unprocessed event … }
BEGINLOOP
Ask Event-Driver (ED) Section [including
Context: PERSON-EVENT
LOOP_03 for each … PERSON-EVENT on Person’s-Medical-Events-Roster WHERE {event remains to be processed}
BEGINLOOP
If … {event-type is hospital-stay}
Ask Hospital-Stay (HS) Section including Charge/Payment (CP) and … including Charge/Payment (CP) and Flat Fee (FF) Sections
endif
If {event-type is outpatient
-
meps.ahrq.gov/survey_comp/overall_p19.shtml
Person
LOOP_02 for each PERSON on RU-Members-Roster WHERE {PERSON continues to have an unprocessed event … }
BEGINLOOP
Ask Event-Driver (ED) Section [including
Context: PERSON-EVENT
LOOP_03 for each … PERSON-EVENT on Person’s-Medical-Events-Roster WHERE {event remains to be processed}
BEGINLOOP
If … {event-type is hospital-stay}
Ask Hospital-Stay (HS) Section including Charge/Payment (CP) and … including Charge/Payment (CP) and Flat Fee (FF) Sections
endif
If {event-type is outpatient}
-
meps.ahrq.gov/survey_comp/overall_p20.shtml
Person
LOOP_02 for each PERSON on RU-Members-Roster WHERE {PERSON continues to have an unprocessed event … }
BEGINLOOP Ask Event-Driver (ED) Section [including
Context: PERSON-EVENT LOOP_03 for each … PERSON-EVENT on Person’s-Medical-Events-Roster WHERE {event remains to be processed} BEGINLOOP If … {event-type is hospital-stay} Ask Hospital-Stay (HS) Section including Charge/Payment (CP) and Flat … (OP) Section including Charge/Payment (CP) and Flat Fee (FF) Sections endif If {event-type is
-
ce.effectivehealthcare.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