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Showing results for "harm".

21. Dashboard Information | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/npsd/data/dashboard/info.html
    June 01, 2019 - Near miss, or Unsafe condition as well as provides other information relevant to all events (e.g., harm … Answer Values: Incident: A patient safety event that reached a patient and either resulted in no harm … (no harm incident) or harm (harm incident). … action by a healthcare practitioner or worker or healthcare circumstance that exposes a patient to harm … first the word is capitalized, and all letters are italicized (e.g., Unsafe condition ; Moderate harm

22. Medication or Other Substance Dashboard | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/npsd/data/dashboard/medication.html
    October 01, 2023 - This dashboard details the incorrect action taken, incorrect action by residual harm to the patient, … type of incorrect dose, type of incorrect dose by residual harm to the patient, stage of process where … event originated, and stage of process where event originated by residual harm to the patient.

23. Device or Medical/Surgical Supply, Including HIT Dashboard | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/npsd/data/dashboard/devices.html
    October 01, 2023 - This dashboard details the type of device; type of device by residual harm to the patient; device defect … , failure, or user error; device defect, failure, or user error by residual harm to the patient; type … technology (HIT) device in HIT-related report; and type of HIT device in HIT-related report by residual harm

24. Module 1: An Overview of the CANDOR Process | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes1.html
    August 01, 2022 - A CANDOR event is an event that involves unexpected patient harm. … The unexpected harm can be physical, emotional, or financial. … Care for the caregivers is frequently absent in the traditional response to harm. … The CANDOR process promotes the value of disseminating lessons learned and solutions to prevent harm … events, and offering compensation for the patient’s harm, when appropriate.

25. Webinar Agenda: Veterans Health Administration’s Journey to High Reliability: Advancing Toward Zero Harm and Becoming a Learning Health System (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/action-alliance/high-reliability-journey-agenda.pdf
    September 26, 2023 - Webinar Agenda: Veterans Health Administration’s Journey to High Reliability: Advancing Toward Zero Harm … September 26, 2023 Veterans Health Administration’s Journey to High Reliability: Advancing Toward Zero Harm

26. Making Healthcare Safer III: Executive Summary | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/research/findings/making-healthcare-safer/mhs3/exe-summary.html
    March 01, 2020 - Starting from the new conceptual framework, we organized the report by “harm areas.” … Identification, Selection, and Prioritization of Harm Area Topics 3. … scan of patient safety resources to identify existing and potentially new harm areas. … Selecting a particular PSP should be based on the root cause of the harm. … It is clear that many factors impact the success of any PSP on reducing harm.

27. Making the Case That Improving Antibiotic Use is a Patient Safety Issue | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/antibiotic-use/acute-care/safety/patient-safety.html
    November 01, 2019 - After viewing or presenting this presentation viewers will be able to— Explain the potential harm … associated with antibiotic use Recognize that patient harm is often preventable Recognize that change … require a focus on systems, not individuals Recognize the importance of diverse input to prevent harm

28. Safer Together: A National Action Plan to Advance Patient Safety | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/reports/safer-together.html
    November 01, 2022 - 2018 by the Institute for Healthcare Improvement and committed to achieving safer care and reducing harm … Though U.S. researchers have identified many evidence-based, effective best practices for harm reduction … Reducing preventable harm requires a total systems approach: a coordinated, proactive strategy in which … precondition to advancing patient safety with a unified, total systems-based approach to eliminate harm

29. What Can Leaders Achieve by Prioritizing Diagnostic Safety? | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/leadership-4.html
    June 01, 2021 - Diagnostic safety is vital to learning health systems committed to eliminating preventable harm … disability stem from an inaccurate or delayed diagnosis, making it the number one cause of serious harm … billion is wasted annually on excessive testing and treatment. 27 This overutilization contributes to harm … It is essential that every healthcare encounter is safe and free from harm. … the entire healthcare continuum that promotes robust collaboration among all stakeholders to prevent harm

30. Developing a Taxonomy for Coding Ambulatory Medical Errors: A Report from the ASIPS Collaborative (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Pace.pdf
    January 01, 2004 - Description of harm For this paper we used a definition of harm that includes clinical harm to the … harm in the ASIPS DMO taxonomy is classified as— • minimal harm - a change in some physiological function … The odds ratio describes the chances of patient harm occurring relative to harm not occurring, given … Individual codes associated with harm Table 3. … Hierarchical constructs associated with harm Table 4.

31. Silence A Commentary | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/reports/liability/silence.html
    August 01, 2017 - Patients and families realize no provider comes to work with the intent to cause harm. … Yet, when harm does occur, and honest and transparent conversations are not conducted, you harm us again … . 5 I believe there is a fifth desire for some patients and families after harm has occurred, and it … Instead of letting fear drive the actions and behaviors after harm, it is the mindset of courage and … RCA: Improving Root Cause analyses and Actions to Prevent Harm.

32. Create a Culture of Safety Around Antibiotic Prescribing | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/antibiotic-use/long-term-care/safety/index.html
    January 01, 2024 - be encouraged to understand both the benefits and risks of antibiotic use and be engaged in reducing harm … Reducing harm often requires changes in thinking and behavior. … providers in creating a safety culture that values appropriate antibiotic prescribing and takes action when harm

33. Module 1: Communication and Optimal Resolution (CANDOR) Toolkit Module 1: An Overview of the CANDOR Process
    ce.effectivehealthcare.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. … The unexpected harm can be physical, emotional, or financial. … Care for the caregivers is frequently absent in the traditional response to harm. … events, and offering compensation for the patient’s harm, when appropriate.

34. Develop a Culture of Safety Around Antibiotic Prescribing | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/antibiotic-use/acute-care/safety/index.html
    June 01, 2021 - be encouraged to understand both the benefits and risks of antibiotic use and be engaged in reducing harm … Reducing harm often requires a change in thinking and behavior. … providers in creating a safety culture that values appropriate antibiotic prescribing and takes action when harm

35. Preventing Falls in Hospitals
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module1/module1_slides_fallprev.pptx
    June 16, 2017 - Falls harm patients. 30% to 51% of falls result in injury. … per 1000 pt days JAH VAMC Med-Surg Falls with Harm by Quarter per 1000 pt days (Includes all harm categories … per 1000 pt days JAH VAMC Med-Surg Falls with Harm by Quarter per 1000 pt days (Includes all harm categories … 0 Quarter harm from falls Pilot Unit (5 South) Harm from Falls per 1000 pt days by Quarter JAH VAMC … 0 Quarter harm from falls Pilot Unit (7 North) Harm from Falls per 1000 pt days by Quarter

36. Learning-Antibiotic-Adverse-Events-Form (doc file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/learning-antibiotic-adverse-events-form.docx
    November 01, 2019 - administration of antibiotics that you would not want to happen again because it either caused your patient harm … or had the potential to cause harm. … Negative contributing factors are those that harmed or increased the risk of harm for the patient. … Positive contributing factors are those that limit the impact of harm.

37. Module 4: Event Reporting, Event Investigation and Analysis | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes4.html
    August 01, 2022 - The goal for an organization implementing the CANDOR process is to increase the reporting of patient harm … Do they believe the organization is aware of all the patient harm events? … to prevent future harm events. … The organization should have a mechanism in place to address anonymous reports of harm events. … Identification of innovative solutions to prevent similar harm events and related hazardous behaviors

38. How To Measure Fall Rates and Fall Prevention Practices
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module5/module5_slides_fallprev.pptx
    December 03, 2012 - . ‹#› 48 JAH VAMC Med-Surg Falls with Harm by Quarter per 1000 pt days (Includes all harm … per 1000 pt days JAH VAMC Med-Surg Falls with Harm by Quarter per 1000 pt days (Includes all harm categories … per 1000 pt days JAH VAMC Med-Surg Falls with Harm by Quarter per 1000 pt days (Includes all harm categories … 0 Quarter harm from falls Pilot Unit (5 South) Harm from Falls per 1000 pt days by Quarter JAH VAMC … 0 Quarter harm from falls Pilot Unit (7 North) Harm from Falls per 1000 pt days by Quarter

39. Antibiotic-Targets-Facilitator-Guide (doc file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/antibiotic-targets-facilitator-guide.docx
    June 01, 2021 - Slide 3 Recognizing Potential Harm SAY: Before we move forward, let’s take a moment to talk about … the potential for patient or resident harm. … Slide 4 Examples of Potential Harm SAY: A few examples of potential harm related to antibiotic use … Moment 4 may have caused the most notable harm in this case. … This type of problem solving generally does not help prevent future harm from occurring.

40. IV. Evaluation Aims, Methods, and Results | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/reports/hotline/eval4.html
    May 01, 2016 - scale, and duration of harm. … , or duration of harm. … Duration of Harm No harm 6 N/A (no harm) Mild harm 12 <1 year: 8 ≥1 year: 0 Unknown … Death 0 No reported events Near miss 1 N/A (no harm) Unsafe condition 8 N/A (no harm … A “near miss” that reaches a patient but does not cause harm is equivalent to an incident with no harm