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pcmh.ahrq.gov/research/findings/making-healthcare-safer/index.html
July 01, 2023 - government agencies about practices that can improve patient safety across the healthcare system—from hospitals … a significant problem in the United States. … Harms such as adverse drug events, healthcare-associated infections, falls, and obstetric adverse events … safety practices in selected harm areas. … facilitating adoption and implementation in a timelier way.
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pcmh.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2016-materials/teamstepps-monthly-webinar-april2016.pptx
January 01, 2016 - 2009
Hospitals participated on a voluntary basis beginning in 2010
19 hospitals ranging in size from … continued annually with over 100 hospitals currently engaged in the project
TEAMSTEPPS 05.2
Mod 1 … 103 hospitals in 16 states
Using TeamSTEPPS for greater than one year
30 additional hospitals in 11 … 133 hospitals in the HCA family using TeamSTEPPS tools by end of 2016
Partnering with the HCA Clinical … team with focus on high functioning teams
Requiring more prescriptive measures of success
Sepsis, Falls
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pcmh.ahrq.gov/patient-safety/settings/multiple/index.html
August 01, 2023 - , home)
Web: ahrq.gov/cahps/surveys-guidance/hospice
Hospitals
Web: ahrq.gov/cahps/surveys-guidance … /hospital
Hospital outpatient and ambulatory surgery centers
Web: ahrq.gov/cahps/surveys-guidance … the hospital and other healthcare environments. … The toolkit addresses approaches to desgin tat target six areas of safety: infections, falls, medication … the following settings:
Hospitals
Web: ahrq.gov/hospsurvey
Medical offices
Web: ahrq.gov/sops
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/updatedhacrateinfo.pdf
June 01, 2014 - methods used to compute
this data are identical to those used to compute the 2010 baseline, as described in … The data for 2011 and 2012 are shown in Table 1 below. … 32,750,000
Discharges—
Based on 2010
Baseline)
2012 PFP
Measured
HACs per
1,000
Discharge
s
Falls … MPSMS In-Hospital Patient
Falls
260,000 7.80 230,000 7.16
Obstetric
Adverse
Events
PSI OB Trauma … in
Vaginal Delivery With
(PSI 18) and Without
Instrument (PSI 19)
82,000 2.51 77,000 2.36
Pressure
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pcmh.ahrq.gov/funding/grantee-profiles/index.html
April 01, 2024 - More >>
Advancing Academic and Practical Knowledge To Prevent Infections From Hospital to Home
Susan … Director, Patient Safety Research Core
Boston Children’s Hospital “AHRQ funding enables researchers … More >>
Reducing Patient Falls with Evidence-based Tools
Patricia Dykes, Ph.D., R.N. … Harvard Medical School, Boston, MA “Patient falls can result in traumatic and costly outcomes. … With AHRQ funding, I’ve been able to provide hospitals and primary care practices with falls prevention
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/spread/spreadnotes.docx
August 28, 2012 - Once hospital leaders are on board, they should appoint a senior executive to the CUSP team to ensure … For example, if a hospital is engaged in an organization-wide improvement initiative to decrease falls … Having the Newborn Critical Care Center complete a falls risk assessment for each patient for each shift … For example, if a hospital wants to spread a new process for patient identification, it can test the … For example, for a falls prevention program, quantitative measures to evaluate can include the falls
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallpxtoolkit/fallpxtool3n.docx
January 01, 2008 - In addition, there may be late manifestations of head injury after 24 hours. … · Notify treating medical provider immediately if any change in observations. … Notify family in accordance with your hospital’s policy. … 3-8 are usually said to be in a coma. … The total score is the sum of the scores in three categories.
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/howtogetstarted/How_PFE_Benefits_Hosp_508.docx
January 01, 2012 - Information to Help Hospitals Get Started
How Patient and Family Engagement
Benefits Your Hospital
Information … In a pilot implementation project, hospitals that implemented the strategies in the Guide observed improved … medication errors, a 40 percent reduction in falls, and a 50 percent decrease in length of stay.4
Improved … care processes.9 When patients and families remain disengaged, hospitals waste resources in the form … of preventable readmissions.18
Enhanced hospital market share and competitiveness
For many hospitals
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pcmh.ahrq.gov/hai/cusp/modules/spread/notes.html
December 01, 2012 - Once hospital leaders are on board, they should appoint a senior executive to the CUSP team to ensure … For example, if a hospital is engaged in an organization-wide improvement initiative to decrease falls … Having the Newborn Critical Care Center complete a falls risk assessment for each patient for each shift … For example, if a hospital wants to spread a new process for patient identification, it can test the … For example, for a falls prevention program, quantitative measures to evaluate can include the falls
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pcmh.ahrq.gov/cahps/surveys-guidance/hospital/about/dev_adult_hp_survey.html
April 01, 2023 - collaboration to foster greater accountability and improvements in hospital care. … This pilot test included 132 hospitals and resulted in over 19,000 completed surveys. … These focus groups were conducted in four cities and included adults who had recently been in a hospital … or who were caregivers for someone who had recently been in a hospital. … In the summer of 2004, the CAHPS Team worked with hospitals and vendors that volunteered to test the
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pcmh.ahrq.gov/patient-safety/reports/advances-new-directions/index.html
July 01, 2022 - Voluntary Adverse Event Reporting in Rural Hospitals ( PDF , 478 KB ) Charles P. … Using ICD-9-CM Codes in Hospital Claims Data to Detect Adverse Events in Patient Safety Surveillance … A Model of Care Delivery to Reduce Falls in a Major Cancer Center ( PDF , 426 KB ) Nancy E. … Using Root Cause Analysis to Reduce Falls in Rural Health Care Facilities ( PDF , 338 KB ) Patricia … Strategies for Improving Patient Safety in Small Rural Hospitals ( PDF , 134 KB ) Judith Tupper, et
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pcmh.ahrq.gov/patient-safety/settings/hospital/resource/pressure-injury/index.html
October 01, 2017 - Fall Prevention in Hospitals Training Program
Hospital Resources
CANDOR
Family-Centered … Hospitals Training Program
AHRQ developed the Pressure Injury Prevention in Hospitals Training … in Hospitals Toolkit . … Hospitals participating in this pilot implementation of the Training Program and Toolkit reduced their … Hospital implementation teams should access the modules in sequential order, view the recommended Webinars
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pcmh.ahrq.gov/patient-safety/settings/hospital/resource/qitool/casestudy.html
December 01, 2017 - Patient Safety Research Summaries
Patient Safety Resources by Setting
Hospital … Fall Prevention in Hospitals Training Program
Hospital Resources
CANDOR
Family-Centered … Hospitals
Re-Engineered Discharge Toolkit
QI Toolkit
Venous Thromboembolism Guide … of hospitals’ performance and in future value-based purchasing programs. … The Healthcare-Acquired Pressure Ulcers and Falls Prevention task forces have achieved similar successes
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pcmh.ahrq.gov/teamstepps-program/curriculum/communication/tools/checkback.html
July 01, 2023 - In an environment where information overload is common, check-backs play a key role in ensuring that … Other examples of effective check-backs include:
One member of the team calls out, "BP is falling, … BP is falling and at 80/48, down from 90/60." … hospital and long-term care settings ( TeamSTEPPS: Check-Back in Inpatient Surgical Terms ; TeamSTEPPS … : Check-Back in Long-Term Care ) and identify each step in the check-back process:
Who was the sender
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pcmh.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursinghome-resourcelist.pdf
April 01, 2023 - 2: Communicating Change in a Resident’s Condition
• Module 3: Falls Prevention and Management
SOPS … a hospital or skilled nursing facility. … The toolkit is designed to aid facilities in developing a comprehensive falls prevention program. … a history of falls.
5. … the Long-Term Care Setting
Falls Management Program
Framework for Improving Joy in Work
Get Connected
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pcmh.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospitalresourcelist.pdf
January 01, 2019 - Improving Patient Safety in Hospitals: A Resource List for Users of the AHRQ Hospital Survey on Patient … Safety Culture
Improving Patient Safety in Hospitals: A Resource List
for Users of the AHRQ Hospital … Fall Prevention in Hospitals Training Program
https://www.ahrq.gov/professionals/systems/hospital/fallpxtraining … Commission National Patient Safety Goals Hospital Program is to
improve patient safety in hospitals … • Patient Falls Reduction.
• RCA Resource Guide.
• SBAR.
15.
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pcmh.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospital-v2-resourcelist.pdf
April 01, 2023 - Safety in Hospitals: A Resource List
for Users of the AHRQ Hospital Survey on Patient
Safety Culture … is to
improve patient safety in hospitals by focusing on specific goals. … • Patient Falls Reduction.
• RCA Resource Guide.
• SBAR.
9. … Fall Prevention in Hospitals Training Program
https://www.ahrq.gov/professionals/systems/hospital/fallpxtraining … Fall Prevention in Hospitals Training Program
10. Framework for Improving Joy in Work
11.
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pcmh.ahrq.gov/sites/default/files/attachments/pcpf-module-11-root-cause-analysis.pdf
September 01, 2015 - in mind: Did the patient come in for services in the performance period? … many of the factors that contribute to a patient’s
falling out of a metric may not be evident to you … these patients’ medical records and other related documents to
identify potential causes for their falling … http://www.ahrq.gov/professionals/systems/hospital/qitoolkit/d5-gapanalysis.pdf . … http://www.ahrq.gov/professionals/systems/hospital/qitoolkit/d5-gapanalysis.pdf
http://www.psnet.ahrq.gov
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pcmh.ahrq.gov/news/newsletters/e-newsletter/index.html
April 30, 2024 - Drug Shortages Occurred in Wake of Pandemic, Study Finds
April 2, 2024
AHRQ Accelerates … March 26, 2024
Studies Summarize Current Evidence on Tools to Treat, Diagnose ADHD Symptoms in … Poor-Performing Hospitals
January 30, 2024
New Tool Helps Manage Opioid Use in Older Adults … Surveillance
October 24, 2023
New Data Resource Provides Insights on Factors Related to Falls … in Healthcare
September 26, 2023
AHRQ Awards $45 Million in Grants To Expand Access to Care
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pcmh.ahrq.gov/hai/cauti-tools/archived-webinars/health-literacy-slides.html
December 01, 2017 - LTC Facilities
Reducing CAUTI in Hospitals
How To Use the Toolkit
Modules
Information … the hospital works and how to achieve results
Are strangers in the hospital environment
Don’t … “If you are concerned about falling (or the family is concerned) please let the hospital staff know because … difficult to walk and/or lead to falls.” … Slide 56
References
Guide to Patient and Family Engagement in Hospital Quality and Safety.