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Showing results for "harm".
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www.ahrq.gov/hai/cusp/modules/learn/index.htmlJuly 01, 2018 - Discusses the effects of errors and patient harm and the underlying causes of errors.
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www.ahrq.gov/hai/tools/mrsa-prevention/toolkit/cusp.htmlOctober 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
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www.ahrq.gov/hai/tools/perinatal-care/modules/teamwork/learn-from-defects-fac-guide.htmlMay 01, 2017 - Sensemaking tools to help reduce the risk of future harm to your patients. … 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? … 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.
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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.docxMay 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 -
Learndefects (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/learndefects.docAugust 08, 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? -
www.ahrq.gov/news/newsroom/case-studies/201620.htmlFebruary 01, 2017 - Traditionally, hospitals and health care providers are not fully forthcoming with patients and families when harm … on its head, providing methods and tools for hospitals and health systems to respond immediately to harm … process as a test in September 2014, Dignity Health had an existing disclosure policy in place regarding harm
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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.pdfApril 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? -
Fall Dashboard Data 2024 (xls file)
www.ahrq.gov/sites/default/files/wysiwyg/npsd/Fall_Dashboard_Data_2024.xlsxJanuary 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 -
www.ahrq.gov/hai/tools/perinatal-care/modules/teamwork/assessment.htmlMay 01, 2017 - 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.
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www.ahrq.gov/pqmp/measures/inpatient-counseling-access.htmlAugust 01, 2021 - Children/Adolescents Who Were Admitted to the Hospital for Dangerous Self-Harm or Suicidality, Should
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www.ahrq.gov/pqmp/measures/suicide-followup-after-discharge.htmlAugust 01, 2021 - Children/Adolescents Who Present to the ED With Dangerous Self-Harm or Suicidality Who Are Discharged
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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.pdfApril 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. -
124-Cusp-Science-Safety-Fg (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/124-cusp-science-safety-fg.docxApril 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. -
www.ahrq.gov/sites/default/files/2024-01/hall1-report.pdfJanuary 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.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Devine.pdfJuly 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
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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. -
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. -
www.ahrq.gov/pqmp/measures/emergency-department-suicide-home.htmlAugust 01, 2021 - Children/Adolescents Who Present to the Emergency Department (ED) With Dangerous Self-Harm or Suicidality
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www.ahrq.gov/pqmp/measures/followup-discussion.htmlAugust 01, 2021 - Children/Adolescents Admitted to the Hospital for Dangerous Self-Harm or Suicidality Should Have Documentation
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/supporting/assessment.docxMay 01, 2017 - 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.
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