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Showing results for "harm".

41. Developing a Taxonomy for Coding Ambulatory Medical Errors: A Report from the ASIPS Collaborative (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Pace.pdf
    January 01, 2004 - Description of harm For this paper we used a definition of harm that includes clinical harm to the … harm in the ASIPS DMO taxonomy is classified as— • minimal harm - a change in some physiological function … The odds ratio describes the chances of patient harm occurring relative to harm not occurring, given … Individual codes associated with harm Table 3. … Hierarchical constructs associated with harm Table 4.

42. Developing a Taxonomy for Coding Ambulatory Medical Errors: A Report from the ASIPS Collaborative (pdf file)
    www.ahrq.gov/downloads/pub/advances/vol2/pace.pdf
    January 01, 2004 - Description of harm For this paper we used a definition of harm that includes clinical harm to the … harm in the ASIPS DMO taxonomy is classified as— • minimal harm - a change in some physiological function … The odds ratio describes the chances of patient harm occurring relative to harm not occurring, given … Individual codes associated with harm Table 3. … Hierarchical constructs associated with harm Table 4.

43. Module 1: An Overview of the CANDOR Process | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes1.html
    August 01, 2022 - process is designed to help health care organizations and practitioners respond to unexpected 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.

44. Chapter 1. Background | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/chapter1.html
    August 01, 2022 - Reviewers List of Tables and Exhibits Evidence documenting health care-associated injury/harm … individual States and health care systems have established reporting systems to detect preventable medical harm … reporting mechanisms, and diversify and augment our understanding of the nature and causes of preventable harm

45. Detailed Findings | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/demo-program/grants/findings.html
    August 01, 2022 - improving patient safety and reducing medical liability: (1) improving communication, (2) preventing harm … Explanation of the reason for harm was provided in 88 percent of cases, and expressions of sympathy ( … Patient and family member experience of medical harm after adverse event. 6 Seventy-two patients and … Harm. 11 Six months following the end of the intervention, the project demonstrated reduction in harm … Harm and clinical measures.

46. Conclusion | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/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

47. Final Progress Report: Patient-centered approach to reducing harm from VTE (pdf file)
    www.ahrq.gov/sites/default/files/2024-07/rothberg-report.pdf
    January 01, 2024 - Final Progress Report: Patient-centered approach to reducing harm from VTE Title: Patient-centered … approach to reducing harm from VTE Principal Investigator: Michael Rothberg, MD, MPH Team Members: … Risk stratification is key to maximizing the ratio of benefit to harm from VTE prophylaxis. … Title: Patient-centered approach to reducing harm from VTE Abstract Purpose SCOPE METHODS RESULTS

48. Making Healthcare Safer III: Executive Summary | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/findings/making-healthcare-safer/mhs3/exe-summary.html
    March 01, 2020 - Starting from the new conceptual framework, we organized the report by “harm areas.” … Identification, Selection, and Prioritization of Harm Area Topics 3. … scan of patient safety resources to identify existing and potentially new harm areas. … Selecting a particular PSP should be based on the root cause of the harm. … It is clear that many factors impact the success of any PSP on reducing harm.

49. New Dashboard Tracks Progress Toward 50 Percent Reduction in Patient and Workforce Harm | Agency for Healthcare Research and Quality
    www.ahrq.gov/news/newsletters/e-newsletter/941.html
    December 01, 2024 - New Dashboard Tracks Progress Toward 50 Percent Reduction in Patient and Workforce Harm Issue Number … Today's Headlines: New Dashboard Tracks Progress Toward 50 Percent Reduction in Patient and Workforce Harm … New Dashboard Tracks Progress Toward 50 Percent Reduction in Patient and Workforce Harm A new online … AHRQ, whose National Advisory Council established a goal of reducing patient and healthcare workforce harm … to monitor the nation's progress on achieving a vision of safe care everywhere and zero preventable harm

50. Webinar Agenda: Veterans Health Administration’s Journey to High Reliability: Advancing Toward Zero Harm and Becoming a Learning Health System (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/high-reliability-journey-agenda.pdf
    September 26, 2023 - Webinar Agenda: Veterans Health Administration’s Journey to High Reliability: Advancing Toward Zero Harm … September 26, 2023 Veterans Health Administration’s Journey to High Reliability: Advancing Toward Zero Harm

51. Final Progress Report: Caregiver innovations to reduce harm in Neonatal Intensive Care (pdf file)
    www.ahrq.gov/sites/default/files/2025-03/thomas-report.pdf
    January 01, 2025 - Final Progress Report: Caregiver innovations to reduce harm in Neonatal Intensive Care … Title: Caregiver innovations to reduce harm … system leaders) perceive as key factors that impacted the ability of QI projects to reduce all-cause harm … Implementing a Robust Process Improvement Program in the Neonatal Intensive Care Unit to Reduce Harm … Project 1: Reducing Unplanned Extubations Abstract Purpose: 1) Measure all-cause preventable harm

52. Silence A Commentary | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/reports/liability/silence.html
    August 01, 2017 - Patients and families realize no provider comes to work with the intent to cause harm. … Yet, when harm does occur, and honest and transparent conversations are not conducted, you harm us again … There are four things patients and families want after medical harm has occurred: tell us what happened … . 5 I believe there is a fifth desire for some patients and families after harm has occurred, and it … RCA: Improving Root Cause analyses and Actions to Prevent Harm.

53. Making the Case That Improving Antibiotic Use is a Patient Safety Issue | Agency for Healthcare Research and Quality
    www.ahrq.gov/antibiotic-use/acute-care/safety/patient-safety.html
    November 01, 2019 - After viewing or presenting this presentation viewers will be able to— Explain the potential harm … associated with antibiotic use Recognize that patient harm is often preventable Recognize that change … require a focus on systems, not individuals Recognize the importance of diverse input to prevent harm

54. Final Progress Report: Pediatric Medication Safety: Analyses from the MEDMARX Medication Error Reporting System (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/bundy-report.pdf
    January 01, 2024 - 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.

55. Gap Analysis Facilitator's Guide: Appendix B | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/apb.html
    August 01, 2022 - Are the costs associated with inappropriate care-related harm events tracked and trended? … Is the investigatory process for harm events designed to afford all members the protections of State … Are bills for hospital or professional fees waived if inappropriate care caused harm? … Have the staff had training related to the vulnerabilities of caregivers involved in harm events? … Is followup provided for staff involved in harm events?

56. Issue Brief 26: Exploration of Foundational Terminology and Paradigms for Improving Diagnosis (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/resources/issue-briefs/dxsafety-terminology.pdf
    April 01, 2025 - or risk of harm. … , or severe temporary harm, as used by the Joint Commission). … The goal is not just to prevent harm, but to achieve success. … The concept of “error without harm” or an error rescued before harm impacts a specific patient is referred … “Never events” and the quest to reduce preventable harm.

57. Learning-Antibiotic-Adverse-Events-Form (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/learning-antibiotic-adverse-events-form.docx
    November 01, 2019 - administration of antibiotics 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 are those that harmed or increased the risk of harm for the patient. … Positive contributing factors are those that limit the impact of harm.

58. Module 4: Event Reporting, Event Investigation and Analysis | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes4.html
    August 01, 2022 - The goal for an organization implementing the CANDOR process is to increase the reporting of patient harm … When a patient harm event occurs, rapid and timely reporting and comprehensive documentation of the details … Do they believe the organization is aware of all the patient harm events? … to prevent future harm events. … The organization should have a mechanism in place to address anonymous reports of harm events.

59. Snac-Final-Report-Mar2023 (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/snac-final-report-mar2023.pdf
    January 01, 2025 - We will not compete on safety: How children’s hospitals have come together to hasten harm reduction … v=h2 JxuySrCw0 ***We stand for a healthcare delivery system that is free from preventable harm and … We will reduce all cause harm across settings of care for patients and the healthcare workforce 75% … The National Action Alliance promotes a holistic awareness of harm, with the aim to ensure patients … and the healthcare workforce are free of physical, emotional , and financial harm.

60. Slide Presentation - Progress Update: The National Action Alliance for Patient and Workforce Safety—What, Why and How? (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/progress-update-2024-slides.pdf
    January 01, 2024 - PSSM Domain Key PSSM Specifications Domain 1: Leadership Commitment to Eliminating Preventable Harm … Domain 2: Strategic Planning • Strategic plan publicly shares hospital commitment to “zero preventable harm … science, analytics, and technology 27 Safety and Resiliency Safety: Achieve Zero Preventable Harm … standards, and quality improvement support KEY ACTIONS TO DRIVE IMPROVEMENTS IN SAFETY AND REDUCE HARM … • Hospital Harm - Falls with Injury • Hospital Harm - Postoperative Respiratory Failure • Patient Safety