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Total Results: 3,156 records

Showing results for "harm".

121. 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)
     www.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

122. Improving Patient Safety Systems for Limited English Proficiency Patients
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/hospitalguide/lephospitalguide.pptx
     January 01, 2011 - Types of Physical Harm Experienced From Adverse Events by English-Speaking and LEP Patients English … Percent Types of Physical Harm Experienced From Adverse Events by English-Speaking and LEP Patients … 366 (46.1%) 89 (40.1%) No harm 194 (24.4%) 24 (10.8%) No detectable harm 177 (22.3%) 58 (26.1%) Minimal … temporary harm 46 (5.8%) 43 (19.4%) Moderate temporary harm 7 (0.9%) 7 (3.2%) Severe temporary harm … Percent Types of Physical Harm Experienced from Adverse Events by English Speaking and LEP Patients

123. Final Progress Report: Pediatric Medication Safety: Analyses from the MEDMARX Medication Error Reporting System (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/16774-Bundy-draft-1.pdf
     September 29, 2009 - medications, situational characteristics, and patient characteristics that are associated with high-harm … than reports of errors that were not associated with harm. … Specific Aim #2: To examine whether the causes of ‘no-harm’ medication errors are the same as those … Hypothesis: The causes and contributing factors for medication errors not resulting in harm will be … Categories E through H errors not only occurred and reached the patient but also caused harm.

124. When It Comes to High-Quality Healthcare, Diagnostic Safety Tops the List | Agency for Healthcare Research and Quality
     www.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.

125. Learning-From-Antibiotic-Adverse (doc file)
     www.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.

126. Inappropriate Disclosure to a Patient: Video | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/videos/inapp-disclosure.html
     August 01, 2022 - practitioners can use to respond in a timely, thorough, and just way when unexpected events cause patient harm … This video demonstrates an example of inappropriate disclosure of harm to a patient.

127. Appropriate Disclosure to a Patient: Video | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/videos/app-disclosure.html
     August 01, 2022 - practitioners can use to respond in a timely, thorough, and just way when unexpected events cause patient harm … This video demonstrates an example of appropriate disclosure of harm to a patient.

128. Communication and Optimal Resolution (CANDOR) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/index.html
     August 01, 2022 - practitioners can use to respond in a timely, thorough, and just way when unexpected events cause patient harm … A traditional approach when unexpected harm occurs often follows a "deny-and-defend" strategy, providing

129. PowerPoint Presentation
     www.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!

130. Making Effective Changes in Antibiotic Decision Making (pdf file)
     www.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.

131. Premier Uses AHRQ Patient Safety Indicators to Improve Safety and Quality, Reduce Costs | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/multicenter-0801-cdom-cquips.html
     April 01, 2017 - Harm avoidance measures—prevention of problems, such as health care-associated infections and adverse … Year two will add harm avoidance and patient satisfaction. … These hospitals are providing input and guidance on developing harm avoidance measures. … Kelly-Cummings and her colleagues are using industry experts to help develop the harm measures project … The PSIs will play a role in understanding harm avoidance and mortality reduction in QUEST, which is

132. Progress Update: The National Action Alliance for Patient and Workforce Safety—What, Why and How? | Agency for Healthcare Research and Quality
     www.ahrq.gov/action-alliance/webinars/progress-update.html
     May 01, 2024 - and discussed plans for how to operationalize and organize toward a 50% improvement in preventable harm

133. Resident Physicians as Champions in Preventing Device-Associated Infections | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/phys-championsgd/index.html
     October 01, 2015 - Infections Preamble and Summary Epidemiology of Invasive Devices and Complications Examples of Patient Harm … Information Preamble Summary Epidemiology of Invasive Devices and Complications Examples of Patient Harm

134. Module 5: Response and Disclosure | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/notes.html
     August 01, 2022 - 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 … appropriate skills and attitudes to communicate with patients, families, and staff after a patient harm

135. Resources by the CMS Patient Safety Structural Measure Domains | Agency for Healthcare Research and Quality
     www.ahrq.gov/action-alliance/resources/measure-domains.html
     April 01, 2025 - Domain 1: Leadership Commitment to Eliminating Preventable Harm: Executive leadership oversees organizational … Domain 2: Strategic Planning and Organizational Policy: Commitment to “zero preventable harm.” … Contents Domain 1: Leadership Commitment to Eliminating Preventable Harm . … Domain 1: Leadership Commitment to Eliminating Preventable Harm Commitment to Advance Patient and Workforce … tools for data entry and analysis and strategic planning to inform unit-based interventions to reduce harm

136. IV. Evaluation Aims, Methods, and Results | Agency for Healthcare Research and Quality
     www.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: 4 Moderate harm 5 <1 year: 3 ≥1 year: 1 Unknown: 1 Severe harm … Unsafe condition 8 N/A (no harm) Service complaint 4 N/A (no harm) Unclassified

137. Person-Centered Preventive Healthcare: Gathering Stakeholder Input on Evidence and Implementation | Agency for Healthcare Research and Quality
     www.ahrq.gov/ncepcr/research/disseminating-evidence/pcph.html
     September 01, 2024 - At the same time, other people get CPS that have no benefit or even cause harm. … Stopping the delivery of CPS that may cause more harm than benefit.

138. Making the Case That Improving Antibiotic Use Is a Patient Safety Issue (pdf file)
     www.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.

139. Learning From Defects Through Sensemaking: Facilitator Notes | Agency for Healthcare Research and Quality
     www.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?

140. Facilitator Guide: Learning From Defects Through Sensemaking (doc file)
     www.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?