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pbrn.ahrq.gov/teamstepps-program/curriculum/situation/overview/index.html
June 01, 2023 - Cross-Monitoring
A harm error reduction strategy that involves:
Monitoring actions of other team
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pbrn.ahrq.gov/npsd/how-does-npsd-work/index.html
February 01, 2024 - valuable resource for research and learning about how to improve patient safety and prevent patient harm
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pbrn.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/afib_topicref.pdf
January 01, 2020 - Catheter Ablation for Atrial Fibrillation: Topic Refinement - Project ID: CRDT0913
Final Topic Refinement Document
Catheter Ablation for Atrial Fibrillation - Project ID: CRDT0913
Date: 05/29/2014
Topic: Catheter Ablation for Atrial Fibrillation – Project ID: CRDT0913
EPC: Pacific Northwest EPC
AHRQ Task O…
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pbrn.ahrq.gov/patient-safety/settings/hospital/fall-prevention/webinar/slides.html
June 01, 2018 - process challenges
Improving compliance
Learning from near falls and falls that do not involve harm … , in addition to learning from falls with harm
Slide 30
Tools
Assessing Fall Prevention Care
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pbrn.ahrq.gov/teamstepps-program/curriculum/mutual/tools/desc.html
July 01, 2023 - putting the well-being of patients or other team members or staff at risk of physical or emotional harm
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pbrn.ahrq.gov/hai/cusp/modules/index.html
August 01, 2019 - negative events in your system and apply CUSP and Sensemaking tools to help reduce the risk of future harm
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pbrn.ahrq.gov/health-literacy/professional-training/informed-choice/audio-script-leaders.html
September 01, 2020 - required prior to all surgery, and for any treatments and procedures that involve a significant risk of harm … organization's informed consent policy should include what constitutes an emergency, such as if irreparable harm
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pbrn.ahrq.gov/talkingquality/explain/communicate/framework.html
December 01, 2022 - included in a quality report: [2]
Care that protects patients from medical errors and does not cause harm
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pbrn.ahrq.gov/talkingquality/resources/comparative-reports/home-health.html
October 01, 2022 - agencies perform on quality measures such as managing daily activities, patient satisfaction, preventing harm
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pbrn.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-1/slides.html
September 01, 2017 - Falls harm patients.
30% to 51% of falls result in injury.
Many falls are preventable. … Slide 28: Annotated Run Chart
Image: Line graph shows JAH VAMC Med-Surg falls with harm by quarter … The Team and its goals should be:
Aligned with its organization’s goals of preventing harm.
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pbrn.ahrq.gov/sites/default/files/wysiwyg/npsd/npsd-patient-safety-culture-brief.pdf
September 01, 2016 - organizations as they strive to eliminate
the factors that contribute to medical errors, patient
harm … errors are treated
not as personal failures, but as opportunities to improve
the system and prevent harm … Improved Safety Culture and Teamwork Climate
Are Associated With Decreases in Patient Harm and Hospital
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pbrn.ahrq.gov/action-alliance/overview/index.html
February 01, 2024 - interested in recommitting our Nation to advancing patient and workforce safety to move toward zero harm
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pbrn.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/pharmsops-composites.pdf
June 19, 2018 - 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
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pbrn.ahrq.gov/news/newsroom/case-studies/201801.html
April 01, 2018 - of care influencing patient safety, including electronic health records (EHRs), to prevent patient harm
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pbrn.ahrq.gov/gam/summaries/inclusion-criteria/index.html
October 01, 2018 - SHARE:
More topics in this section
Guidelines and Measures
About NGC and NQMC
Guideline and Measure Summaries
NGC and NQMC Inclusion Criteria
NQMC Measure Domain Framework
NQMC Measure Domain Definitions
Updates
…
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pbrn.ahrq.gov/patient-safety/reports/advancing/index.html
July 01, 2022 - Nearly 100 grants were awarded to lay the groundwork for reducing harm to patients. … Using Simulation To Prevent Harm
Patients can sometimes be harmed unintentionally as clinicians learn … Much of the time the harm is not serious; however, some procedures, such as complex surgical operations … likelihood that they are among the first health care professionals to recognize errors and prevent harm
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pbrn.ahrq.gov/patient-safety/reports/national-academy-medicine.html
February 01, 2018 - Sometimes the harm is caused by an error in prescribing or taking the medication, and these damages are
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pbrn.ahrq.gov/patient-safety/settings/ambulatory/diagnostic-safety/toolkit.html
November 01, 2018 - for improving care
Access tools and best practices from national experts
Reduce the likelihood of harm
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pbrn.ahrq.gov/patient-safety/resources/index.html
December 01, 2022 - hospital-acquired conditions is an important patient safety goal, because hospital-acquired conditions cause harm
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pbrn.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospitalresourcelist.pdf
January 01, 2019 - CANDOR) process to respond in a timely, thorough, and just way when unexpected events
cause patient harm … Missed nursing care is linked to patient harm, including falls and infections. … • Identify system vulnerabilities that could lead to patient harm. … ,
• Assist interdisciplinary teams in proactively identifying opportunities for reducing
patient harm … are designed to help alert
hospitals and focus their efforts on errors that cause serious patient harm