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Total Results: 3,207 records

Showing results for "harm".

141. 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?

142. Acute Care Learning From Defects
     www.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.

143. National Action Alliance Webinar June 18, 2024: Empowering Patient Voice in Safety Strategies (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/action-alliance-webinar-june-2024.pdf
     January 01, 2024 - Way Safer Together Team of Teams Key Factors • Relentless Pursuit of the Vision of Zero Harm … then North America Solutions for Patient Safety OUR MISSION: Working together to eliminate serious harm … 1,627 HAC Teams Support & Commitment from 140+ Organizational Executives The SPS Journey Toward Zero Harm … • Receive assessment and training tools to support local efforts to reduce diagnostic harm. … Pictures Collaboration: Ohio and then North America Children’s Hospitals The SPS Journey Toward Zero Harm

144. Understanding and Reducing Overuse of Potentially Harmful Screening Tests (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/decision/research-centers/sheridan_screening_overuse.pdf
     January 01, 2014 - Stacey Sheridan, MD MPH AHRQ Grant Number: P01 HS021133 It is just a screening test; what is the harm … While many screening tests are beneficial, some do more harm than good. … How can a screening test cause harm? … educational materials we learned that:  Fewer than half of patients recognize that screening can cause harm

145. Pediatric Diagnostic Safety Research and Initiatives Across the Care Continuum | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-pediatric-safety-3.html
     August 01, 2023 - addition, leading organizations in pediatric safety have begun efforts to educate about, study, and reduce harm … Care . 60 Nonetheless, MDOs occur even in this setting designed to identify new diagnoses well before harm … diagnoses, rarer and atypical presentations may go unrecognized, exposing patients to more risk of harm … visits. 81 Overall, the existing literature suggests that identifying, learning from, and reducing harm … these observations into effective and feasible interventions that can prevent misdiagnosis-related harm

146. Prologue—Volume 2—Systems Thinking and Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Schyve.pdf
     April 27, 2005 - This should come as no surprise, given that “first, do no harm” has been the ethical watchword throughout … of techniques that we might employ to bring reality closer to the ideal of doing no (preventable) harm … The realization of the magnitude of this failure and that there are potential routes to reducing harm … Even today, preventable patient harm is too often associated with error—usually human error—both within … How can we intervene to prevent harm from unintended consequences?

147. New York City Uses AHRQ Patient Safety Culture Survey to Reduce Patient Harm | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/cquips0901.html
     October 01, 2014 - New York City Uses AHRQ Patient Safety Culture Survey to Reduce Patient Harm Search All Impact Case … multi-year campaign to improve the culture of safety across the organization and reduce chances for patient harm

148. Improving Safety for Patients with Limited English Proficiency: TeamSTEPPS
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2013-materials/teamstepps-monthly-webinar-oct2013.pptx
     January 01, 2013 - 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

149. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/grand-rounds-presentation-slides.pptx
     January 01, 2014 - Some organizations struggle to improve the way they and their care teams respond to medical harm. … The CANDOR process aims to change that. 1 Do Less Harm Video 2 Module 1 To get started, let’s watch … Video: Do Less Harm 2 Presentation Goals Highlight the gap between optimal response to medical injury … It is about reducing HARM. Ask what is responsible…not who is responsible. … An understanding of the changes that have been made to prevent harm to another patient.

150. National Action Alliance for Patient and Workforce Safety Commitment (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/naa-commitment-statement.pdf
     March 12, 2024 - Alliance for Patient and Workforce Safety Commitment Vision Safe care everywhere, zero preventable harm … safety and well-being; and learning health system development toward our vision of zero preventable harm

151. Standardizing Medication Error Event Reporting in the U.S. Department of Defense (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Nosek.pdf
     March 01, 2004 - determined that a significant number of such events do have the potential to cause serious patient harm … error, harm includes Categories E–I events … § No harm definition: An event that reached the patient but did not result in harm. ** Harm definition … Additionally, 9 of the 10 leading “harm” drugs in the DoD data and 8 of the 10 leading “harm” drugs … Percentage of inpatient and outpatient events, stratified by harm and reported Table 2.

152. Final Progress Report: Utility of Predictive Systems in Diagnostic Errors (UPSIDE) (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/auerbach-report.pdf
     January 01, 2025 - Errors contributed to temporary harm, permanent harm, or death in 436 (17.8% of patients, 95% CI 15.9% … For each case with an error, we assessed the extent of the error's contribution to patient harm using … the NCC-MERP scale, which provides explicit definitions of harm (e.g., considering an error to have … was judged to have contributed to temporary harm, permanent harm, or death in 77.1% (95% CI 72.3%-81.9% … For instance, determining the potential for patient harm based on the timing of test results and the

153. A New Model of Thinking in Clinical Preventive Services (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/decision/research-centers/new_model_thinking.pdf
     February 01, 2014 - help save lives, but not everyone realizes that preventive services also have the potential to cause harm … preventive services to be of value, the potential for benefit must be greater than the potential for harm

154. 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

155. Conclusion | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/state-of-science-4.html
     June 01, 2020 - data gathering, HCOs have a variety of options to begin measurement to reduce preventable diagnostic harm … any setting to assess how they could begin their journey to measure and reduce preventable diagnostic harm

156. National Healthcare Quality and Disparities Report Chartbook on Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/patientsafety/qdr2016-ptschartbook.pdf
     July 19, 2017 - Conditions Near-Miss Patient Event, No Harm Patient Event, Harm N u m b e r o f Ev e n ts …  Common Types of Event and Harm: ■ Events that reached the patient—with or without harm—were … of patient harm is known. … “High harm” refers to the number of patient safety event reports submitted to CHPSO with severe harm … of patient harm is known.

157. 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

158. Learn From Defects in Care of Mechanically Ventilated Patients: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/modules/cusp/learn-from-defects-slides.html
     February 01, 2017 - harm. 1 Image: Man wearing jeans and orange/black striped T-shirt sitting with hands raised to chin … What can you do to prevent or minimize this harm? … or risk of harm, decreased it, or was not applicable. … or risk of harm, decreased it, or was not applicable. … or risk of harm, decreased it, or was not applicable.

159. Communication and Optimal Resolution (CANDOR) Toolkit | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules.html
     August 01, 2022 - practitioners can use to respond in a timely, thorough, and just way when unexpected events cause patient harm … Organizational Learning and Sustainability “We realize mistakes happen, and we can forgive that; but you harm … Generally, the CANDOR process begins with identification of an event that involves harm.

160. 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