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Showing results for "harm".

21. Implementation Guide for the CANDOR Process | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/impguide.html
    August 01, 2022 - reference for organizational leaders who are committed to improving their response to unexpected patient harm … report, To Err Is Human: Building a Safer Health System , the problems associated with injury and harm … the United States provides some of the best health care in the world, unsafe health care processes harm … This statistic represents only one type of patient harm that results during the delivery of patient care … A CANDOR event is defined as an event that involves unexpected harm (physical, emotional, or financial

22. Network of Patient Safety Databases Falls Chartbook, 2023 (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-falls-chartbook-2023.pdf
    January 01, 2023 - While the AHRQ Harm Scale provides the following possible responses: No harm, Mild harm, Moderate … harm, Severe harm, Death, or Unknown harm, due to small counts across the categories of Moderate to … Severe harm, this Chartbook displays falls where the EXTENT OF HARM is categorized as No harm, Harm … (i.e., Mild harm, Moderate harm, Severe harm, or Death), or Unknown harm. … For this figure, all Incident reports with EXTENT OF HARM reported are displayed as either No harm, Harm

23. Foundational Terminology for Diagnosis Relating to Suboptimal Processes and Outcomes | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-terminology7.html
    April 01, 2025 - References The early attention on improvement for diagnosis responded to cases of harm … problematic for diagnosis as most diagnostic errors are real but generally not tangible (except for the harm … e.g., difference between admitting and discharge diagnoses). 39,40   Near-Miss Not all errors cause harm … The concept of “error without harm” or an error rescued before harm impacts a specific patient is referred … If someone intervenes to prevent harm, it is sometimes referred to as a good catch . 11 Undesirable

24. 2024 Network of Patient Safety Databases Chartbook (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-medication-chartbook-2024.pdf
    January 01, 2024 - The AHRQ Harm Scale captures Residual harm to the patient after any intervention to reduce harm. … While the AHRQ Harm Scale provides the following possible responses: No harm, Mild harm, Moderate harm … as No harm, Harm (i.e., Mild harm, Moderate harm, Severe harm, or Death), or Unknown harm. … , moderate harm, and mild harm to the patient. … Harm (i.e., Mild harm, Moderate harm, Severe harm, or Death), or Unknown due to small counts across

25. Blood Dashboard Data (xls file)
    www.ahrq.gov/sites/default/files/wysiwyg/npsd/Blood_Dashboard_Data_2024.xlsx
    January 01, 2024 - reports by type of blood product, by the process of care involved, and by the extent of residual patient harm … Blood_2 Blood_2: Type of Blood Product by Extent of Residual Harm Type of Blood Product No Harm Percentage … No Harm Frequency Harm Percentage Harm Frequency Red blood cells 96.7% 2,096 3.3% 72 Plasma 98.9% … Stage of Process When Blood or Blood Product Event Originated No Harm Percentage No Harm Frequency … Harm Percentage Harm Frequency Post-transfusion or administration 99.3% 414 * * Unknown 98.3% 283

26. Commitment To Advance Patient and Workforce Safety | Agency for Healthcare Research and Quality
    www.ahrq.gov/action-alliance/commitment/index.html
    October 01, 2024 - commitment strengthens the community as it continues its collective journey towards zero preventable harm … 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

27. Conceptual Paradigms of Diagnostic Quality, Safety, and Excellence | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-terminology5.html
    April 01, 2025 - or risk of harm. … actions, diagnostic safety can refer to two different types of harm. … harm, as used by the Joint Commission).  … The goal of Safety-I is to prevent, avoid, minimize, or mitigate error and harm. … The goal is not just to prevent harm, but to achieve success.

28. Grand Rounds Presentation | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/grand-rounds.html
    August 01, 2022 - 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 … to provide excellent, high-quality medical care, but despite all of our patient safety work, patient harm … Medicare data: 13.5% of hospitalized beneficiaries experienced an adverse event. 1.5% experienced harm … An understanding of the changes that have been made to prevent harm to another patient.

29. NPSD Data Spotlight: Patterns of Fall Interventions (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-patterns-fall-interventions.pdf
    September 01, 2023 - For this analysis, reported EXTENT of HARM were further dichotomized as either No harm or Harm (i.e … ., Mild harm, Moderate harm, Severe harm or Death). … Specifically, we examined the no-harm rate, or the percentage of falls that resulted in no harm to … harm to the patient. … Events Resulting in No Harm to Patient No-harm Rate (%) Low bed, Items in reach, Visible

30. Network of Patient Safety Databases Chartbook, 2019 (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2019.pdf
    January 01, 2019 - No Harm, or Harm (i.e., Mild harm, Moderate harm, Severe harm or Death). … No Harm, or Harm (i.e., Mild harm, Moderate harm, Severe harm or Death). … No Harm, or Harm (i.e., Mild harm, Moderate harm, Severe harm or Death). … No Harm, or Harm (i.e., Mild harm, Moderate harm, Severe harm or Death). … No harm, or Harm (i.e., Mild harm, Moderate harm, Severe harm or Death).

31. Network of Patient Safety Databases Chartbook, 2023 (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2023-rev.pdf
    January 01, 2023 - Residual harm is captured by AHRQ’s Harm Scale and is defined as harm to the patient after discovery … harm, Moderate harm, Severe harm, Death, or Unknown harm. … Incident events where the EXTENT OF HARM is categorized as No harm, Harm, or Unknown harm. … harm, Mild harm, Moderate harm, Severe harm, Death, or Unknown harm. … events where the EXTENT OF HARM was reported as No harm, Harm, or Unknown harm.

32. Module 1: Communication and Optimal Resolution (CANDOR) Toolkit Module 1: An Overview of the CANDOR Process
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/module1-overview.pptx
    June 02, 2025 - Unsafe Condition Near Miss No Harm Event CANDOR Event Actual harm to patient Potential patient harm … A CANDOR event is an event that involves unexpected patient harm. … The unexpected harm can be physical, emotional, or financial. … Care for the caregivers is frequently absent in the traditional response to harm. … events, and offering compensation for the patient’s harm, when appropriate.

33. NPSD Dashboards | Agency for Healthcare Research and Quality
    www.ahrq.gov/npsd/data/dashboard/index.html
    September 01, 2024 - The dashboard charts detail event type, report type by event type, extent of harm by event type, event … type by extent of harm, and extent of harm.   … Blood Product Dashboard Details the type of blood product involved, type of blood product by residual harm … Falls Dashboard Details the extent of harm due to falls, the presence of fall assistance, presence of … fall assistance by patient harm, type of fall injury, and fall location.      

34. New Dashboard to Track Progress Toward 50 Percent Reduction in Patient and Workforce Harm | Agency for Healthcare Research and Quality
    www.ahrq.gov/news/newsroom/press-releases/new-national-healthcare-safety-dashboard.html
    December 01, 2024 - New Dashboard to Track Progress Toward 50 Percent Reduction in Patient and Workforce Harm Press Release … director on healthcare improvement efforts, has established a goal of reducing patient and workforce harm … significant step toward leveraging Departmental data to advance safe care everywhere and zero preventable harm … The NAA catalyzes change by applying known harm reduction strategies, sharing best practices and lessons

35. VHA's Journey to High Reliability: Advancing Toward Zero Harm and Becoming a Learning Health System
    www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/high-reliability-journey-slides.pptx
    September 26, 2023 - VHA's Journey to High Reliability: Advancing Toward Zero Harm and Becoming a Learning Health System … September 26, 2023 Pre-Decisional Deliberative Document Internal VA Use Only Advancing Toward Zero Harm … VA Use Only ‹#› 2 VHA’s Journey to High Reliability Foundation Pivotal studies on patient harm … environments Fewer than anticipated accidents or events of harm An “accident or event of harm” could … Culture of Safety Safety values and practices are used to prevent harm and learn from mistakes.

36. Learning From Diagnostic Errors | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-psychological-safety-1.html
    September 01, 2023 - define and enumerate diagnostic errors, but we are often reminded by patients and clinicians of the harm … Successful approaches to learn from diagnostic quality and develop strategies to reduce harm from diagnostic

37. Learn from Defects Tool | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/cusp/toolkit/learn-defects.html
    December 01, 2012 - This could include incidents 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. … of harm) to the incident?

38. Final Progress Report: Transdisciplinary Learning Lab To Eliminate Patient Harm and Reduce Waste (pdf file)
    www.ahrq.gov/sites/default/files/2025-03/sapirstein-report.pdf
    January 01, 2025 - Learning Lab to Eliminate Patient Harm and Reduce Waste Johns Hopkins Medicine Principal Investigator … Apply SE framework to address a common, preventable harm in the intensive care unit (ICU) 3. … The Causal Loop Model for Susceptibility to Preventable Harm in the ICU. … Managing Data Requirements to Measure ICU Susceptibility to Patient Harm. … Managing data requirements to measure ICU susceptibility to patient harm.

39. NAA National Webinar, February 2025: Establishing Psychological Safety for Healthcare Workers (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/psychological-safety-slides.pdf
    March 18, 2025 - • Are you aware of any “near misses” in your area that could have caused harm? … Psychological Safety • Transparency is a pre-condition for patient safety* • Clinicians involved in harm … safety *Credit: Julie Morath Why Do We Struggle to Respond to Harm Events? … 9b: Implement and maintain programs for providing appropriate ongoing support in the aftermath of harm … The Ultimate Stress Test for Psychological Safety Why Do We Struggle to Respond to Harm Events?

40. Medication Dashboard Data 2024 (xls file)
    www.ahrq.gov/sites/default/files/wysiwyg/npsd/Medication_Dashboard_Data_2024.xlsx
    January 01, 2024 - Harm Frequency Percent Incorrect dose(s) No Harm 13,693 93.7% Incorrect dose(s) Harm 916 6.3% Incorrect … Harm 331 80.3% Contraindicated for the patient Harm 81 19.7% Incorrect rate No Harm 1,222 95.5% Incorrect … rate Harm 57 4.5% Allergen to the patient No Harm 104 75.4% Allergen to the patient Harm 34 24.6% … Incorrect patient No Harm 1,151 96.7% Incorrect patient Harm 39 3.3% Incorrect preparation No Harm … medication/substance Harm * * Multiple No Harm 2,654 87.2% Multiple Harm 390 12.8% Other: Please