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Showing results for "event".

81. Exhibit 13. Probability of intervention reducing risk of surgical site infection (SSI) by multiple concurrent interventions at various reductions of noncompliance rates (25, 5 | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/findings/final-reports/stpra/stpraexh13.html
    April 01, 2018 - References for Fault Tree Model Probability Estimates References Event Event … 30 Gate 239 Event 142 Event 659 Event 138 25% reduction in noncompliance Event 30 … puncture – – – 0.0042 0.0041 Event 138 Fail to remove watch/jewelry/fake nails – … puncture – – – 0.0040 0.0037 Event 138 Fail to remove watch/jewelry/fake nails – … puncture – – – 0.0039 0.0034 Event 138 Fail to remove watch/jewelry/fake nails –

82. Sepsis: recognizing the next event. | PSNet
    psnet.ahrq.gov/issue/sepsis-recognizing-next-event
    July 13, 2010 - Commentary Sepsis: recognizing the next event. … Sepsis: recognizing the next event. … Sepsis: recognizing the next event.

83. Mod4-System-Focused-Event-Guide (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4/mod4-system-focused-event-guide.pdf
    April 01, 2016 - The sole objective of the event investigation and analysis of an adverse event or near miss is the … Principles of an Event Review In other safety critical industries, event reviews are highly routinized … event Occurs at: ■ 30 days ■ 60 days ■ 90 days 6 – System-Focused Event Investigation and Analysis … that led up to the event. 6. … Culture ■ Was this event placed in the patient safety event reporting system?

84. Exhibit 9. Top five minimal cut sets for the basic case | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/findings/final-reports/stpra/stpraexh9.html
    April 01, 2018 - reduction Event 142 (0.3) Staff not well-trained in infection control Event 450 (0.293) … Event 182 (0.2) Fail to administer indicated antibiotics Event 543 (0.0325) SSI risk for … reduction Event 142 (0.3) Staff not well-trained in infection control Event 450 (0.293) … Event 30 (0.125) Fail to prepare skin appropriately Event 543 (0.0325) SSI risk for obese … reduction Event 450 (0.293) Obese, but not diabetic, patient (30Event 642 (0.2)

85. Exhibit 10. Probability variations used in the sensitivity analyses | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/findings/final-reports/stpra/stpraexh10.html
    April 01, 2018 - Range Considered Event 21 Patient fails to follow instructions for smoking cessation 0.13 to … 0.30 Event 28 Patient colonized with MRSA 0.10 to 0.30 Event 29 Non-MRSA patient 0.90 … to 0.70 Event 136 Fail to wash hands properly (OR staff) 0.12 to 0.40 Event 142 Staff … (staff) 0.20 to 0.40 Event 203 Fail to wash hands (non-OR staff) 0.10 to 0.60 Event … 404 Poor postoperative directions to patient 0.15 to 0.50 Event 405 Patient understands, but

86. Disparities in adverse event reporting for hospitalized children. | PSNet
    psnet.ahrq.gov/issue/disparities-adverse-event-reporting-hospitalized-children
    July 27, 2022 - Study Disparities in adverse event reporting for hospitalized children. … Disparities in adverse event reporting for hospitalized children. … Voluntary event reporting (VER) systems are required in most hospitals, but their effectiveness is … Disparities in adverse event reporting for hospitalized children. … May 18, 2022 Adverse event reporting priorities: an integrative review.

87. Exhibit 11. Importance measures on events in rank order of criticality | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/findings/final-reports/stpra/stpraexh11.html
    April 01, 2018 - Birnbaum Fussell– Vesely Event 642 Fail to protect patient effectively (failure related … to skin prep, antibiotics admin, shaving surgical site, etc.) 0.5187 0.0113 0.5187 Event … 450 Obese, but not diabetic, patient (30 < BMI < 40) 0.3147 0.0047 0.3147 Event 543 SSI … Event 659 Glove puncture 0.1550 0.0038 0.1550 Event 30 Fail to prepare skin appropriately … Event 419 Patient fails to come for post-op visit 0.1162 0.0034 0.1162 Event 136 Fail

88. Dashboard Information | Agency for Healthcare Research and Quality
    www.ahrq.gov/npsd/data/dashboard/info.html
    June 01, 2019 - Dashboard Information NPSD Dashboards display data that follow the Common Formats for Event Reporting … – Hospital Version (CFER-H) definitions of Adverse Events, i.e., the Common Formats Event Descriptions … There are 10 CFER-H modules: one Generic module applies to all reported events, and nine event-specific … The event-specific modules provide additional and more detailed information about the following nine … Near miss: An event that did not reach a patient.

89. Patient perspectives on adverse event investigations in health care. | PSNet
    psnet.ahrq.gov/issue/patient-perspectives-adverse-event-investigations-health-care
    December 18, 2024 - Study Patient perspectives on adverse event investigations in health care. … Patient perspectives on adverse event investigations in health care. … After an adverse event, the way hospitals involve families plays a significant role in the families' … perspectives of the event. … Patient perspectives on adverse event investigations in health care.

90. 'Connecting the dots': leveraging visual analytics to make sense of patient safety event reports. | PSNet
    psnet.ahrq.gov/issue/connecting-dots-leveraging-visual-analytics-make-sense-patient-safety-event-reports
    May 29, 2024 - 'Connecting the dots': leveraging visual analytics to make sense of patient safety event … 'Connecting the dots': leveraging visual analytics to make sense of patient safety event reports. … a way to reduce the burden of analyzing internal incident reports, increase awareness of adverse event … 'Connecting the dots': leveraging visual analytics to make sense of patient safety event reports. … from patient safety event report databases.

91. Exhibit 3. Reporting of patient safety events | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/exh3.html
    August 01, 2022 - Information about the event flows to system users: primary system audience of consumers; and other potential … Type of event: harm event, no harm event, near miss. … Event details: who, what, where, etc. (Use structured input in a common reporting format.) … Reporting can be at any time, during or after the event. … real-time reporting, but caution reporters that the system is not a substitute for calling 911 in the event

92. Common Formats for Event Reporting. | PSNet
    psnet.ahrq.gov/issue/comments-common-formats-event-reporting-hospital-version-03-beta
    September 06, 2011 - Measurement Tool/Indicator Common Formats for Event Reporting. … Citation Text: Common Formats for Event Reporting. National Quality Forum. … URL Cite Citation Citation Text: Common Formats for Event … for comments on the proposed measures and 2020 targets for the National Action Plan for Adverse Drug Event

93. Exhibit 2.9. Lean Project Activities | Agency for Healthcare Research and Quality
    www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit2-9.html
    November 01, 2014 - Pre-event Create charter. Select team members. … Prepare individuals for their roles in Lean event. … Post-RCI Event Implement all changes on Monday following the event (sometimes sooner). … Track event week metrics and post in common area. … Send out weekly communications and updates to staff during 1st month after the event.

94. Hospital Evacuation Decision Guide (Table 6) | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/shuttered/hospevactab6.html
    July 01, 2018 - Implications Event Characteristics Arrival When is the event expected to … How variable is the time the event is expected to "hit"? … Magnitude What is the expected strength of the event? … Duration How long is the event expected to last? … How variable is the expected duration of the event?

95. Is excessive resource utilization an adverse event? | PSNet
    psnet.ahrq.gov/issue/excessive-resource-utilization-adverse-event
    February 02, 2022 - Commentary Is excessive resource utilization an adverse event? … Is Excessive Resource Utilization an Adverse Event? … Is Excessive Resource Utilization an Adverse Event? … Problem September 1, 2014 Families as partners in hospital error and adverse event

96. Care of the clinician after an adverse event. | PSNet
    psnet.ahrq.gov/issue/care-clinician-after-adverse-event
    March 03, 2021 - Review Care of the clinician after an adverse event. … Care of the clinician after an adverse event. … Care of the clinician after an adverse event. … National Partnership for Maternal Safety: consensus bundle on support after a severe maternal event

97. Module 6: Care for the Caregiver | Agency for Healthcare Research and Quality
    www.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.

98. System-Focused Event Investigation and Analysis Guide | Agency for Healthcare Research and Quality
    pbrn.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4.html
    August 01, 2022 - Principles of an Event Review In other safety critical industries, event reviews are highly routinized … The most effective event investigation and analyses are conducted as quickly as possible after the event … that led up to the event. … stakeholders to understand the event. … No reinvestigation of the event.

99. System-Focused Event Investigation and Analysis Guide | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4.html
    August 01, 2022 - Principles of an Event Review In other safety critical industries, event reviews are highly routinized … The most effective event investigation and analyses are conducted as quickly as possible after the event … that led up to the event. … stakeholders to understand the event. … No reinvestigation of the event.

100. Integrating adverse event reporting into a free-text mobile application used in daily workflow increases adverse event reporting by physicians. | PSNet
     psnet.ahrq.gov/issue/integrating-adverse-event-reporting-free-text-mobile-application-used-daily-workflow
     March 17, 2021 - Study Integrating adverse event reporting into a free-text mobile application used … in daily workflow increases adverse event reporting by physicians. … Adverse Event Reporting by Physicians. … Adverse Event Reporting by Physicians. … participation in adverse event reporting.