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Showing results for "harm".

181. Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Health Care March Meeting Summary (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/topics/meeting-summary-031720.pdf
     July 23, 2020 -  VA participation in Patient Safety Measures of Hospital Harm Technical Expert Panel (TEP). … The project aims to develop measures of hospital harm for use in CMS quality and payment programs,

182. Indwelling Urinary Catheter Insertion Facilitator Notes (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-catheter-insertion-notes.docx
     April 01, 2022 - Healthcare providers want to minimize or prevent harm to patients. … But when a mistake is made during urinary catheter insertion, the harm is not immediately apparent. … Unless we are mindful, we will not be aware of the possible harm we are causing. … an invasive device is inserted, and a thoughtful approach to preventing that harm. … However, the inserter needs to be mindful that any invasive device can cause harm.

183. The Incident Decision Tree: Guidelines for Action Following Patient Safety Incidents (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Meadows.pdf
     December 01, 2003 - The four tests The deliberate harm test In the overwhelming majority of patient safety incidents, … However, the deliberate harm test helps to identify at the earliest possible stage those rare cases … where harm was intended. … When it appears deliberate harm was intended, the importance of immediate suspension, together with … Doing less harm. 2001 Aug. 3. U.K. Department of Health. Staff in the NHS 2002.

184. A Model for Sustaining and Spreading Safety Interventions | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/hai/cauti-tools/guides/sustainability-guide.html
     October 01, 2015 - Potential or Actual Harm or “Defects” A defect is any clinical event or situation that a staff member … It includes any incident that someone believes caused patient harm or put a patient at risk of harm. … What can be done to minimize harm or prevent safety hazards? … Patient names can be associated with each harm event to remind staff that there is a real person is behind … Many units will post a “days since the last________ (harm event, e.g., CLABSI).”

185. Quantitative and Qualitative Analysis of Medication Errors: The New York Experience (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Duthie.pdf
     January 01, 2004 - The errors included were those that resulted in a severity of patient harm that met the National Coordinating … Medication Error Reporting Program (NCC MERP) criteria for categories G (resulting in permanent patient harm … The NCC MERP definitions for outcome categories—G (resulting in permanent harm), H (resulting in near … -G- An error occurred that may have contributed to or resulted in permanent patient harm. 109 A … The data includes only those errors that result in the most serious harm.

186. Final Progress Report: Drug-Drug Interaction Clinical Decision Support Conference Series (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/2024-01/malone-report.pdf
     January 01, 2024 - small subset of known and potentially clinically significant DDIs.8 Although the exact magnitude of harm … The magnitude of harm, frequency, and factors that may modify the risk were considered to be important … evidence evaluation of DDI literature should include suggested approaches to minimize or eliminate harm … Risk factors that may decrease or increase the risk of harm associated with a DDI should be included … Furthermore, suggesting strategies to actively monitor for signs of harm for patients on concomitant

187. Measure Dx: A Resource To Identify, Analyze, and Learn From Diagnostic Safety Events (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/publications2/files/MeasureDx-guide.pdf
     July 01, 2022 - of harm … Spread and Improvements � Increased efforts to measure diagnostic harm. … No Harm � Category A- Circumstances or events that have the capacity to cause error Error, No Harm … to the patient and/or required intervention to preclude harm Error, Harm � Category E- An error occurred … /little or no remediation Minor Harm/remediation or treatment Considerable Harm/remediation or treatment

188. Identify Defects Through Sensemaking | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/hai/cusp/modules/identify/identify.html
     December 01, 2012 - negative events in your system and apply CUSP and Sensemaking tools to help reduce the risk of future harm … Step 3: What can be done to minimize harm or prevent safety hazards? … 12: Exercise Please complete the following: List all defects that have the potential to cause harm

189. 6 Tk1 T1-Talking With Residents Final (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/nhguide/6_TK1_T1-Talking_with_Residents_Final.pdf
     October 01, 2016 - • Unneeded antibiotics can do more harm than good. … • Before taking an antibiotic, it is important to understand how antibiotics could harm or hurt you …  Decrease your risk of experiencing any harm, including C. diff infections and antibiotic resistance

190. Figure 11: Comparison of Audit Techniques | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/match/figure-11.html
     July 01, 2022 - Tracks the type of discrepancies, number of interventions, drug/drug class involved, harm averted, etc … High-risk areas can be targeted for this evaluation to avoid potential harm (e.g., intensive care units

191. Community Pharmacy Survey on Patient Safety (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/pharmacy/toolkit/PharmSOPSform.doc
     June 09, 2016 - ► Patient safety is the prevention of patient harm resulting from the processes of health care delivery … or quality-related event, regardless of whether or not it reaches the patient or results in patient harm … When a mistake reaches the patient and could cause harm but does not, how often is it documented? … When a mistake reaches the patient but has no potential to harm the patient, how often is it documented

192. Appendix C: The Health Care Safety Hotline: Operations Manual (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/hotline/healthcare-safety-hotline-appendixc.pdf
     July 01, 2015 - scale, and duration of harm. … There are six levels of harm in the Common Formats: unknown, no harm, mild harm, moderate harm, severe … harm, and death. … (no-harm incident) or harm (harm incident). … (no-harm incident) or harm (harm incident).

193. Special Considerations for Measurement of Diagnostic Safety (continued) | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/reports/issue-briefs/state-of-science-2b.html
     June 01, 2020 - shed light on the frequency or scope of a problem, but they can help raise awareness of the impact and harm … review may be sufficient to identify missed opportunities for diagnosis, contributing factors, and harm … Other factors related to diagnostic error, such as the presence of patient harm (e.g., clear evidence … of harm versus “near-misses”), preventability, and actionability, may also be important to define in

194. How To Avoid the Harms of Antibiotic Overuse | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/education-bundles/urine-culturing/antibiotic-stewardship/part-1-slides.html
     February 01, 2019 - It won't do any harm. Probably the urine. Needs an antibiotic.

195. A Model for Sustaining and Spreading Safety Interventions: AHRQ Safety Program for Reducing CAUTI in Hospitals (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/publications/files/sustainability-guide_2.pdf
     September 01, 2015 - Potential or Actual Harm or “Defects” A defect is any clinical event or situation that a staff member … It includes any incident that someone believes caused patient harm or put a patient at risk of harm. …  What can be done to minimize harm or prevent safety hazards? … Patient names can be associated with each harm event to remind staff that there is a real person is … ahead.”10 Aside from an organization’s overall survival, each patient who is spared an HAI or other harm

196. 6 Tk1 T2-Talking With Residents Family Members Final (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/nhguide/6_TK1_T2-Talking_with_Residents_Family_Members_Final.pdf
     October 01, 2016 - • Unneeded antibiotics can do more harm than good. … Toolkit/Tool 2 4 • Before taking an antibiotic, it is important to understand how antibiotics could harm …  Decrease the likelihood that residents experience any harm, including C. diff infections and antibiotic

197. Reducing Harms from Unsafe Use of Antibiotics and Preventing the Spread of Antibiotic Resistance | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/funding/grantee-profiles/grtprofile-trautner.html
     October 01, 2023 - Skip to main content An official website of the Department of Health and Human Services Careers Contact Us Español FAQs Search all AHRQ sites Search small Search Menu …

198. Ambulatory Procedure/Surgery Center Survey on Patient Safety (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/resources/asc-survey.docx
     June 06, 2018 - . ► Patient safety is the prevention of harm resulting from the processes of health care delivery. … prevention includes reducing mistakes, errors, incidents, events, or problems that lead to patient harm … 2 3 4 5 9 SECTION D: Near-Miss Documentation ► When something happens that could harm

199. Staffsafetyassess (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/staffsafetyassess.doc
     August 06, 2012 - Please describe what you think can be done to prevent or minimize this harm.

200. Fundamentals of Medicare Patient Safety Surveillance: Intent, Relevance, and Transparency (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Hunt.pdf
     July 01, 2004 - The MPSMS explicit review is a patient-centered process focusing on patient harm rather than provider … Definition of variables and explicit criteria An adverse event is defined as an unintended harm, injury … Webster’s New World Dictionary defines safety as “the condition of being free from harm, injury, or … In this definition, the operative words are “patient” and “harm.” 4 Not addressed is the concept of … This focus on patient harm, with limited consideration of mitigating factors, is our definition of