Results

Total Results: 2,182 records

Showing results for "harm".

421. Nursing Home Resources | Agency for Healthcare Research and Quality
     www.ahrq.gov/nursing-home/resources/search.html
     January 01, 2022 - All Cause Harm Prevention in Nursing Home—Events Related to Infections ​This document is a section of … the All Cause Harm Prevention in Nursing Homes Change Package.

422. Engage the Team and Applying CUSP in the ICU Setting Slides (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cusp-icu-notes.docx
     April 01, 2022 - checks for key processes, we improve our ability to reduce the risks of adverse events resulting in harm … , ICUs can still make changes in systems or processes to make their units safer and prevent patient harm … compel the team to make changes by providing an example of when inaction (or action) led to patient harm … Keep in mind that process defects may be identified that did not cause harm but put patients at risk … for harm, such as a breach in aseptic technique when inserting a central line.

423. Learn About the Comprehensive Unit-based Safety Program for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-about-cusp-fac-guide.html
     July 01, 2023 - The CUSP framework accomplishes this through stressing the fact that patient harm is not an acceptable … communication tools were effective in reducing lapses in team functioning, errors, and the likelihood of harm … choices should be emphasized more than the outcome of the choices, which may or may not have resulted in harm … Transparency is also vital in addressing system factors that may contribute to harm.

424. Engageexecnotes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/engage/engageexecnotes.docx
     June 02, 2025 - example of adaptive work in which CUSP teams help unit staff understand the effects of preventable harm … risks because team members are responsible for holding each other accountable for reducing patient harm … Display statistics that show the positive effects of the CUSP initiative in the areas surrounding patient harm … among hospital staff, which will ultimately increase patient safety and reduce unnecessary expenses and harm … Infection rate data, stories of recent near-misses, or instances of harm are imperative for the executive

425. Eliciting Patients’ Diagnostic Experiences Using Rigorous Methods | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-3.html
     June 01, 2023 - These mistakes sometimes result in no harm, while other times they may result in additional or prolonged … Virtually every respondent who reported a persisting harm identified at least one action they wished

426. Facilitator-Notes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module2/facilitator-notes.docx
     March 01, 2017 - Any staff member can complete this assessment, highlighting areas of concern or potential harm that the … across the organization, to capture information about high-risk situations that could lead to resident harm … across the organization, capture information about high-risk situations that could lead to patient harm … Provide statistics that show the positive effects of the project in reducing resident harm or the average … Within the 4 Es model, you want to engage facility staff in understanding the effects of preventable harm

427. Appendix B. Search Terms | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/engage/appb.html
     March 01, 2017 - Adverse events Just culture Error reporting Reporting culture Communication Error Harm

428. Reporting of Adverse Drug Events: Examination of a Hospital Incident Reporting System (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Desikan.pdf
     March 01, 2002 - events (errors that caused no harm or were intercepted before they reached the patient) captured by … Level A events have the potential to do harm but do not reach the patient. … Level B events have potential for harm and reach the patient, but cause no harm. … Events at this level reach the patient and either lead to harm or require an increase in monitoring. … The Institute of Medicine report on medical errors: Misunderstanding can do harm.

429. Ventilator-Associated Event Surveillance: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/modules/vae/surveillance-fac-guide.html
     February 01, 2017 - Slide 5: Connect the Safety Dots Say: The use of any invasive device can lead to harm. … While these are all life-saving events, there is a potential for harm. … In this schematic you can see some of the causes for and outcomes associated with ventilator harm. … As we connect the dots to harm, it’s important to look at the clinical ramifications of VAE.

430. Evolving Methods and the Future of Diagnostic Improvement | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-terminology9.html
     April 01, 2025 - continues to advance understanding and support progress in improvement, including recognition of potential harm

431. Implementation Change Management | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps-program/curriculum/implement/activity/change.html
     June 01, 2023 - Regrettably, some organizations acquire a sense of urgency only when a tragic and publicized patient harm … In some cases, inconveniences are not taken seriously by healthcare organizations and harm results (e.g … Highlighting patient stories of both harms and harm avoidance that contrast a culture of safety with

432. AHRQ Quality Indicators Toolkit Facilitates Process Improvement Work at Cedars-Sinai Medical Center | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/resource/qitool/casestudy.html
     December 01, 2017 - Everyone is held responsible for actions to mitigate potential patient harm. … disciplines are assigned to carry out a "leave-no-stone-unturned" search for opportunities to prevent harm

433. Issue Brief 9: Improved Diagnostic Accuracy Through Probability-Based Diagnosis (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/dxsafety-probabilistic-thinking.pdf
     September 01, 2022 - Introduction Errors that occur during the diagnostic process can lead to missed or wrong diagnoses and can harm … risks” and “benefits” vs. the more neutral, transparent, and quantifiable comparison of “chance of harm … of patient benefit and harms, tests, like all other health services, will either help patients or harm … results and subsequent missed diagnoses that are truly causing symptoms, with potential for patient harm

434. NICU Toolkit: Family Information Packet Cover Sheet (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-cover.pdf
     June 02, 2025 - infant’s care must be well coordinated and clearly communicated to avoid medical errors that could harm

435. Ceosnrleaderchcklst (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/ceosnrleaderchcklst.docx
     June 02, 2025 - Require that the appropriate office (e.g., Infection Prevention) produce a weekly report of harm, disseminate

436. Resident Physicians as Champions in Preventing Device-Associated Infections Pocket Guide (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/guides/resphys-champions-pocketgd.pdf
     June 02, 2025 - Indwelling devices that HEAL may also HARM! Use them only when necessary.

437. Variation in the Implementation of California's Full-Service Partnerships | Agency for Healthcare Research and Quality
     www.ahrq.gov/practiceimprovement/delivery-initiative/gilmerstudysnapshot/index.html
     April 01, 2015 - They emphasize consumer choice, self-determination, and independence; actively use harm reduction, motivational … Similarly, 76 percent endorsed a harm-reduction approach to substance use, and most adhered to standards

438. Module 2: Senior Leader Engagement: Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module2/mod2-facguide.html
     March 01, 2017 - Any staff member can complete this assessment, highlighting areas of concern or potential harm that the … across the organization, to capture information about high-risk situations that could lead to resident harm … across the organization, capture information about high-risk situations that could lead to patient harm … Provide statistics that show the positive effects of the project in reducing resident harm or the average … Within the 4 Es model, you want to engage facility staff in understanding the effects of preventable harm

439. Faclearncusp (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/learn/faclearncusp.docx
     January 01, 2009 - to apply the CUSP Toolkit in a clinical environment, and · Review the effects of errors and patient harm … The CUSP framework accomplishes this through stressing the fact that patient harm is not an acceptable … and spread practices that would reduce or even eliminate the likelihood that patients would suffer harm … communication tools were effective in reducing lapses in team functioning, errors, and the likelihood of harm … · What can be done to minimize the risk of harm?

440. National Action Alliance for Patient and Workforce Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/action-alliance/index.html
     Patient and Workforce Safety Join the National Action Alliance in our progress toward zero preventable harm