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Showing results for "harm".
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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.pdfMarch 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. -
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.pdfJanuary 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 -
www.ahrq.gov/hai/tools/surgery/tools/applying-cusp/perioperative-asst.htmlDecember 01, 2017 - What do you think can be done to prevent this harm? … NAME (OPTIONAL) JOB TITLE DATE CLINICAL AREA ASSESS RISK FOR HARM … Please describe what you think can be done to prevent or minimize this harm.
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www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/advance-organizational-safety-strategies-slides.pdfJune 18, 2024 - • Using this to transform who we are and how we work Aligning our Strategies Healing without Harm … All rights reserved. 33 UHG Journey Toward High Reliability Goal: Eliminate harm and achieve optimal … Innovation & Insights Embrace new techniques to eliminate harm and achieve optimal clinical quality … incorporates evolving evidence- based best practices with the aim of eliminating specific types of harm … incorporates evolving evidence-based best practices with the aim of eliminating specific types of harm
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes6.htmlAugust 01, 2022 - possible to patients, health care providers are sometimes faced with the aftermath of adverse patient harm … detailed information concerning the elements of disclosure to patients and families following a patient harm … track" process that allows the caregiver to quickly access support and guidance following a patient harm … Slide 8 Say: The stages of healing after an unanticipated patient harm event are much … Addressing an intense fear of the unknown following a patient harm event.
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/understanding-cms-patient-safety-measure-hospitals-webcast.pdfJuly 08, 2025 - (PCHQR) Program 6 PSSM 5 Domains • Domain 1: Leadership Commitment to Eliminating Preventable Harm … qualitynet.cms.gov/pch/measures/safety Domain 1: Leadership Commitment to Eliminating Preventable Harm … to safety as core value • Hospital should publicly acknowledge ultimate goal of “zero preventable harm … with the governing board and hospital staff, and used to inform unit-based interventions to reduce harm … and inform improvement activities on safety events (such as: medication errors, surgical/procedural harm
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-current-state1.htmlJanuary 01, 2024 - error in the outpatient setting every year, 1 and approximately 0.7 percent of inpatients experience harm … Findings have several implications for future resource investments to reduce harm from diagnostic errors
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Tuinen.pdfMarch 01, 2004 - was on determining whether groups of ICD codes could be used for statewide surveillance of patient harm … Both harm and the degree to which the AEs were due to care management were operationalized by rating … Surveillance Using ICD-9-CM Surgery Codes 247 Surgery AEs were defined as harm events related to … Roughly one in five codes in these classes referred to patient harm present at admission. … The institute of medicine report on medical errors⎯could it do harm?
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170-Cusp-Science-Safety-Notes (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/170-cusp-science-safety-notes.docxOctober 01, 2024 - Slide 2 Patient Safety and Preventable Harm SAY: Healthcare has focused on safety since the Institute … The impact of preventable harm on our 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 … If there’s one thing that gives hope to teams who wish to protect patients from harm, it is that change … Patient harm is largely preventable. Change efforts require a focus on systems, not individuals. -
Sensemakingnotes (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/identify/sensemakingnotes.docxJune 02, 2025 - recurring defects in your system and apply CUSP and Sensemaking tools to help reduce the risk of future harm … What can be done to minimize harm or prevent safety hazards? … 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 did not happen—No harm event · Event did not reach the patient—Near-miss event We then ask why -
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.pdfMay 01, 2017 - Sensemaking tools to help reduce the risk of future harm to your patients. … cheese model portrays how defects permeate the L&D unit-level systems and contribute to patient harm … What can be done to minimize harm or prevent safety hazards? … The consequent event is described in terms of the event’s consequences: • Harm that did happen • … Harm that did not happen—No-harm event • Event did not reach the patient—Near- Slide 13 Sensemaking
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/dx-leadership.pdfJune 03, 2021 - Errors involve common conditions and nearly half of them have potential for patient harm. … diagnostic errors, as they have with progress made in addressing other forms of preventable patient harm … 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 … It is essential that every healthcare encounter is safe and free from harm. Table 2.
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/dx-leadership-cx.pdfJune 03, 2021 - Errors involve common conditions and nearly half of them have potential for patient harm. … diagnostic errors, as they have with progress made in addressing other forms of preventable patient harm … 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 … It is essential that every healthcare encounter is safe and free from harm. Table 2.
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www.ahrq.gov/hai/pfp/hacrate2013.htmlJanuary 01, 2018 - Although the precise causes of the decline in patient harm are not fully understood, the increase in … Introduction Much attention has been focused on preventing patient harm since the Institute of Medicine's … a spotlight on patient safety but also highlighted the fact that making progress to reduce patient harm … Persistent support for research focused on understanding health care harm—why it occurs, what can be … PfP is a fully aligned "full-court press" to achieve two aims: 40 percent reduction in preventable harm
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www.ahrq.gov/sites/default/files/wysiwyg/nhguide/6_TK1_T5-Suspect_a_Urinary_Tract_Infection_brochure_MA_Coalition_final.pdfJune 02, 2025 - How Taking Antibiotics When You Don’t Need Them Can Cause More Harm Than Good Did You Know That … How Antibiotics Can Cause More Harm Than Good Older people have more side effects from medicines, which … develop new symptoms. »Cause nausea, vomiting or diarrhea. »Cause rashes or allergic reactions. »Harm
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110-Ss-Lfd-Sample (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/110-ss-lfd-sample.docxApril 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? -
Tool: Perioperative Staff Safety Assessment (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/tools/applying-cusp/perioperative_asst.docxDecember 01, 2017 - What do you think can be done to prevent this harm? … Staff Safety Assessment NAME (OPTIONAL) JOB TITLE DATE CLINICAL AREA ASSESS RISK FOR HARM … Please describe what you think can be done to prevent or minimize this harm. -
www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes8.htmlAugust 01, 2022 - The entire CANDOR process fosters a culture of improvement around the response to unexpected patient harm … make the necessary changes that promote a timely, thorough, and just response to unexpected patient harm … training in the CANDOR process, the organization can continue to learn from errors and prevent similar harm … Ask patients and family members to share their stories to put a human face on a harm event and engage … Ask staff to share their stories of patient harm.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module7/module7-resolution-facilitator.pptxAugust 24, 2015 - Following patient harm events, the patient and/or family might sue the caregiver and/or organization, … the Resolution team include: Compensating quickly and fairly when inappropriate medical care causes harm … Creating a learning organization in which patient harm is reduced through ongoing learning from patient … When harm occurs, patients often express the desire to protect others from future events. … Becoming a learning organization supports the goal of preventing similar harm to patients in the future
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Module 5: Component Kit (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/visual/visual-mgmt-component-kit.docxMay 01, 2017 - 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. … observations and any training or safety meetings HRET call 10 am Number of Procedures since last harm … ###1 Ardella Ruffo A16:00 ####4 Safety Check 4 5 6 7 Our Surgery Center “Excellence in Safety: No Harm
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