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Showing results for "harm".

41. Improving the Value of Patient Safety Reporting Systems (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Pronovost_95.pdf
    June 12, 2008 - While there is wide variation relative to how harm is classified,16, 17 we believe harm can be biological … in the harm classification section. … That is, the odds that an event will result in harm. … ) to weakest (least likely to reduce harm). … A weaker intervention would mitigate harm.

42. Table 6: Categories of Medication Error Classification | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/match/table-6.html
    August 01, 2012 - Error that did not reach the patient NA C Error that reached patient but unlikely to cause harm … Error that reached the patient and could have necessitated monitoring and/or intervention to preclude harm … was ordered for patient instead of extended-release E Error that could have caused temporary harm … medication was inadvertently omitted from the orders F Error that could have caused temporary harm … daily when the patient takes it every other day G Error that could have resulted in permanent harm

43. An Overview of the CANDOR Process
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4/module4-event-reporting-investigation-analysis.pptx
    September 10, 2015 - Do they believe the organization is aware of all the patient harm events? … Protects patients from future harm events. … to prevent future harm events.   … The organization should have a mechanism in place to address anonymous reports of harm events. … Event Near Miss Unsafe Conditions Actual Harm to Patient Potential Harm to Patient One of the hallmarks

44. Making Healthcare Safer III: Structured Abstract | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/research/findings/making-healthcare-safer/mhs3/abstract.html
    March 01, 2020 - Identification, selection, and prioritization of harm area topics. … sensitive events, procedural events, and diagnostic errors; and the report covers 47 PSPs in 17 specific harm … While the team was going through the process of selecting PSPs to address specific harm areas, it became … that a wide range of factors impact the effectiveness of PSPs with respect to their ability to prevent harm

45. PowerPoint Presentation
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/antibiotic-targets-slides.pptx
    June 01, 2021 - science of safety Improve teamwork and communication Recognize current practices that may lead to patient harm … Steps for Improving the Culture of Patient Safety 3 3 Identifying Targets 3 Recognizing Potential Harm … Describe what you think can be done to prevent this from happening How Can You Identify Potential Harm … problem solving Solves one problem in one particular instance Generally does not help prevent future harm … Start with a problem or potential harm that is easy to fix.

46. Staff-Safety-Assessment (doc file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module2/staff-safety-assessment.docx
    March 01, 2017 - Modules Staff Safety Assessment Purpose: To tap into your experience to determine risks that could harm … You will need details to understand how you can prevent harm. … Please describe what you think can be done to prevent or minimize this harm. 16-0003-03-EF AHRQ Pub

47. Intravenous Infusion Safety Initiative: Collaboration, Evidence-Based Best Practices, and “Smart” Technology Help Avert High-Risk Adverse Drug Events and Improve Patient Outcomes (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Maddox_38.pdf
    March 26, 2008 - Introduction “First, do no harm” is the ethical imperative for every patient safety effort. … Analysis of Prevented ADEs and Associated Harm In July 2003, an innovative harm-assessment tool was … innovative tool allowed us to assess the extent of harm averted by the system. … The harm and costs averted using this technology are substantial. … Application of the IV Medication Harm Index to assess the nature of harm averted by “smart” infusion

48. Learning-From-Antibiotic-Adverse (doc file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/learning-from-antibiotic-adverse.docx
    June 01, 2021 - any event or situation 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 increase the risk of harm. We want to change these. … Positive contributing factors limit the impact of harm. We want to keep these.

49. Blood and Blood Product Dashboard | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/npsd/data/dashboard/blood.html
    October 01, 2023 - This dashboard details the type of blood product involved, type of blood product by residual harm to … patient, stage of process where event originated, and stage of process where event originated by residual harm

50. New York City Uses AHRQ Patient Safety Culture Survey to Reduce Patient Harm | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/news/newsroom/case-studies/cquips0901.html
    October 01, 2014 - Case Studies New York City Uses AHRQ Patient Safety Culture Survey to Reduce Patient Harm … Events New York City Uses AHRQ Patient Safety Culture Survey to Reduce Patient Harm … multi-year campaign to improve the culture of safety across the organization and reduce chances for patient harm … Internet Citation: New York City Uses AHRQ Patient Safety Culture Survey to Reduce Patient Harm

51. Learning From Defects Through Sensemaking: Facilitator Notes | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-fac-notes.html
    December 01, 2017 - A defect can be a specific harm to a patient. … What can you do to prevent this harm or SSI? … Ask: Can you give an example of a patient harm? … Ask: Did the factor increase the harm or the risk for harm or decrease it? … What can I do to prevent that harm?

52. Grand Rounds Presentation | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/grand-rounds.html
    August 01, 2022 - Some organizations struggle to improve the way they and their care teams respond to medical harm. … to provide excellent, high-quality medical care, but despite all of our patient safety work, patient harm … Slide 30 Say: What we have learned from patients and families after a serious harm event is … that every hour that goes by without effective communication results in additional harm to the patient … An understanding of the changes that have been made to prevent harm to another patient.

53. PowerPoint Presentation
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/antibiotic-patient-safety-slides.pptx
    June 01, 2021 - Safety 1 Objectives Discuss the potential harms associated with antibiotic use Recognize that patient harm … Strive to reduce preventable harm by identifying problems that cause harm to residents. … Recognize current practices that may lead to patient harm. … Create independent checks to reduce potential harm. … Strive to eliminate preventable harm!

54. Making Effective Changes in Antibiotic Decision Making (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/changes-facilitator-guide.pdf
    November 01, 2019 - Identify interventions to reduce future harm associated with unnecessary antibiotic use 3. … Using one of the areas of harm, acute kidney injury from unnecessary vancomycin, let’s consider how … as well as those that had the potential to cause harm. … Positive contributing factors are factors that limited the impact of harm. … ensure that solutions are implemented and harm is reduced.

55. Making the Case That Improving Antibiotic Use Is a Patient Safety Issue (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/patient-safety-facilitator-guide.pdf
    November 01, 2019 - SAY: By the end of this presentation, participants will be able to:  Explain the potential harm … associated with antibiotic use  Recognize that patient harm is often preventable  Recognize … Slide 4 Antibiotic-Associated Adverse Events SAY: All antibiotics have the potential to harm … other hospitals with antibiotic-associated adverse events, and we may not always be aware of the harm … Regardless of whether antibiotics are necessary or not, they can be associated with harm.

56. Summary of Patient Safety Research Opportunities | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/news-events/summit-research-2020/questions.html
    March 01, 2021 - of Social Determinants of Health and Systemic Racism on Patient Safety Understanding and Reducing Harm … Understanding and Reducing Harm caused by Diagnostic Errors How are diagnostic errors within and across … events, including psychological/emotional harm, interventions that expand collection and analysis … What can be done immediately to increase the rate of improvement and harm reduction on a larger scale … voice in reporting patient safety events and enlist patients and caregivers in helping to mitigate harm

57. Learn From Defects in Care of Mechanically Ventilated Patients: Facilitator Guide | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/hai/tools/mvp/modules/cusp/learn-from-defects-fac-guide.html
    February 01, 2017 - A defect can be a specific harm to a patient. … or risk for harm. … Ask: What factors contributed to, minimized, or prevented harm? … risk for harm? … With supporting data, show your staff the reduced risks for patient harm.

58. Acute Care Learning From Defects
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/changes-slides.pptx
    November 01, 2019 - Identify relevant factors that could improve antibiotic use Identify interventions to reduce future harm … 10 Antibiotic-related adverse events are events that either caused harm or had the potential to cause … harm. … patient (want to change these) Positive contributing factors – Factors that limited the impact of harm … Work with all relevant team members to determine solutions to prevent future harm.

59. Facilitator Guide: Learning From Defects Through Sensemaking (doc file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects_facnotes.docx
    December 01, 2017 - A defect can be a specific harm to a patient. … 2) What can you do to prevent this harm or SSI? … ASK: Can you give an example of a patient harm? … ASK: Did the factor increase the harm or the risk for harm or decrease it? … What can I do to prevent that harm?

60. When It Comes to High-Quality Healthcare, Diagnostic Safety Tops the List | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/news/blog/ahrqviews/diagnostic-safety-tops-the-list.html
    March 01, 2024 - Among those patients, about 18 percent of errors caused temporary harm, permanent harm, or death. … errors that persist throughout all care settings, involve common and rare diseases, and continue to harm … They underscore the imperative to mitigate diagnostic errors and harm.