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Showing results for "harm".

121. Module 5: PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/visual/visual-mgmt.pptx
     May 01, 2017 - Ambulatory Surgery Management Practices for Sustainability Key outcome measures Days since last harm … 221 Werner  111 Carletta  221 Safety training chart Date Revised Number of Procedures since last harm … Date Opportunity Action Results Smith ASC Excellence in Safety: No Harm … Keep track of count of procedures since last harm incident each day update the board. … ###1 Ardella Ruffo  A16:00 ####4 Safety Check 4 5 6 7 Our Surgery Center “Excellence in Safety: No Harm

122. 129-Ss-Blank-Lfd (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/129-ss-blank-lfd.docx
     April 01, 2025 - This could include incidents, such as a surgical site infection (SSI), that you believe caused patient harm … or put patients at risk for significant harm. … Negative contributing factors are those that harmed or increased the risk of harm for a patient. … Positive contributing factors limited the amount of harm. … harm) to the incident?

123. PowerPoint Presentation: Learn From Defects Through Sensemaking
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects.pptx
     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: Did the factor increase the harm or the risk for harm or decrease it? … What can I do to prevent that harm? … What can I do to prevent that harm?

124. Tool: Two-Challenge Rule | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps-program/curriculum/mutual/tools/rule.html
     May 01, 2023 - requested clarification but the response or confirmation does not ease the concern about potential harm … the Two-Challenge Rule to situations where the patient or another team member may be at high risk of harm … Can you think of times when using this rule could have prevented harm to a patient?

125. National Healthcare Safety Measures | Agency for Healthcare Research and Quality
     www.ahrq.gov/action-alliance/national-measures/index.html
     April 01, 2025 - National Action Alliance for Patient and Workforce Safety is "safe care everywhere, zero preventable harm … for all," with a goal to reduce patient and workforce harm by 50 percent from its pandemic-driven high

126. 124-Cusp-Science-Safety-Fg (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/124-cusp-science-safety-fg.docx
     April 01, 2025 - Slide 2 Patient Safety and Preventable Harm SAY: Healthcare has focused on safety since the Institute … Infections SAY: The risk of healthcare-associated infections, or HAIs, is a major contributor to patient harm … The impact of preventable harm on the ability to provide safe, effective, and value-based healthcare … their colleagues how they think the next patient will be harmed and what can be done to prevent that harm … Slide 29 Key Takeaways SAY: In conclusion, patient harm is largely preventable.

127. Fall Dashboard Data 2024 (xls file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/Fall_Dashboard_Data_2024.xlsx
     January 01, 2024 - tables include the relative frequencies of reports by age group, by the extent of residual patient harm … of Frequent Intervention Patterns Among Patients Ambulating Prior to Falls that Resulted in Residual Harm … Frequent Intervention Patterns Among Patients Ambulating Prior to Falls that Resulted in NO Residual Harm … of Frequent Intervention Patterns Among Patients Toileting Prior to Falls that Resulted in Residual Harm … NO Residual Harm Falls_10 Comparison of Frequent Intervention Patterns for Falls that Resulted in

128. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/module5-response-disclosure-notes.pptx
     August 21, 2015 - Engages in subsequent disclosure communications with the patient/family about the harm event. … designated communicator will engage in followup communication with the patient and/or family about the harm … The patient and/or family have a reasonable expectation to be informed when a harm event has occurred … Patients and families can be engaged as partners in organizational discussions about harm prevention … training appropriate individuals to communicate with patients, families, and staff after a patient harm

129. Labor and Delivery Unit Staff Safety Assessment | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/assessment.html
     July 01, 2023 - Include any relevant examples that you observed/were concerned about involving patient harm that could … Please describe what you think can be done to prevent or minimize this harm.  

130. Exhibit 3. Reporting of patient safety events | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/exh3.html
     August 01, 2022 - Type of event: harm event, no harm event, near miss.

131. Final Progress Report: Evaluation of Risk by Active Surveillance in the Emergency Department (ERASED) (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/hall1-report.pdf
     January 01, 2024 - The occurrence of harm was also determined. … Fourteen (7%) of the reported events were associated with patient harm. … When there was enough information, both reviewers had to agree on the occurrence of harm. … In a majority of cases, there was no clear report on harm. … For both reporting systems, 7% of the reported events were determined to have caused harm.

132. The Comprehensive Unit-based Safety Program (CUSP) for MRSA Prevention | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mrsa-prevention/toolkit/cusp.html
     October 01, 2024 - the frontline staff and focuses on promoting changes in thinking and behavior to reduce preventable harm … In this section, we take a step back and observe the impact of medical errors and preventable harm and … Psychological Safety CUSP encourages – and relies – on frontline staff to speak up if they observe preventable harm

133. Learn-From-Defects-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.docx
     May 01, 2017 - Comprehensive Unit-based Safety Program, or CUSP, Sensemaking tools to help reduce the risk of future harm … the holes symbolize the opportunities for defects to permeate established systems and cause patient harm … What can be done to minimize harm or prevent safety hazards? … of safety assessment by completing the following: List all defects that have the potential to cause harm … The consequent event is described in terms of the event’s consequences: Harm that did happen Harm that

134. Mod03-Gap-Analysis-Guide (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module3/mod03-gap-analysis-guide.pdf
     April 01, 2016 - Are bills for hospital or professional fees waived if inappropriate care caused harm? 6. … Is followup provided for staff involved in harm events? … Are the costs associated with inappropriate care- related harm events tracked and trended? … Are bills for hospital or professional fees waived if inappropriate care caused harm? … Is followup provided for staff involved in harm events?

135. Stay Up To Date and Engage With the National Action Alliance | Agency for Healthcare Research and Quality
     www.ahrq.gov/action-alliance/overview/contact.html
     June 01, 2024 - helping to realize the National Action Alliance's vision of safe care everywhere and zero preventable harm

136. Final Progress Report: Patient Safety and the Primary Care Testing Process (pdf file)
     www.ahrq.gov/sites/default/files/2025-04/elder-report.pdf
     January 01, 2025 - In addition, events had been assigned to a severity of harm category, ranging from no harm to a range … and 141 events with no harm to classify into the initial Human Factors-Testing Process model. … and no-harm events. … 4. 5 In both the harm and no-harm groups, the return of results step had the largest number of … Rural community members’ perceptions of harm from medical mistakes.

137. Preparing for Ambulatory Computerized Prescriber Order Entry by Evaluating Preimplementation Medication Errors (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Devine.pdf
     July 01, 2003 - temporary patient harm F An error occurred that resulted in initial or prolonged hospitalization … and caused temporary patient harm G An error occurred that resulted in permanent patient harm H … basis, could result Advances in Patient Safety: Vol. 2 192 in patient harm, and consequently … A copy of the Laboratory Harm Table is available from the investigators. … The team reasoned that drug-disease interactions are addressed, in part, by the Laboratory Harm Table

138. Final Progress Report: Toward safer opioid prescribing for chronic pain in high risk populations (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/robinson-papp-report.pdf
     January 01, 2024 - To do so without causing harm, particularly in populations at risk for disparities such as PWH and chronic … functional treatment goals, opioid agreements, prescription drug monitoring programs, opioid benefit/harm … Follow-up and re-evaluate risk of harm within 1-4 weeks of a dose increase and at least every 3 months … otherwise; reduce dose or taper and discontinue if harm outweighs benefit. 8. … To be more precise, the harm to some pain patients that occurred following the CDCOPG is actually the

139. Risk-Based Patient Safety Metrics (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Scanlon_62.pdf
     March 25, 2008 - Although injury-based metrics might aid the prevention of harm, limitations include poor discrimination … Additionally, not all patient harm is preventable. … be discharged without accurate documentation and coding to reflect the harm event. … This is particularly true of “near-miss” and “no- harm” errors, which do not cause harm and yet might … herald significant potential harm to patients.

140. Mod01-Grand-Rounds-Slides (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/grandrounds/mod01-grand-rounds-slides.pdf
     April 01, 2016 - Some organizations struggle to improve the way they and their care teams respond to medical harm. … Video: Do Less Harm Slide 2 Say: Today’s Presentation Goals are to: ■ Highlight the gap between … provide excellent, high-quality medical care, but despite all of our patient safety work, patient harm … ■ 1.5% experienced harm that contributed to their death. … ■ An understanding of the changes that have been made to prevent harm to another patient.