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Showing results for "harm".
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-catheter-insertion.pptxApril 01, 2022 - There can be potential harm involved when an invasive device is inserted, and a mindful approach can … be used to help prevent that harm. … However, the inserter needs to be mindful that any invasive device can cause harm.
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/state-of-science-3.htmlJune 01, 2020 - goals should include: Creating learning opportunities from past events with both potential and real harm … better correlated with not just more timely and accurate diagnosis but also less preventable diagnostic harm
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www.ahrq.gov/hai/cauti-tools/phys-championsgd/section6.htmlOctober 01, 2015 - Infections Preamble and Summary Epidemiology of Invasive Devices and Complications Examples of Patient Harm
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www.ahrq.gov/hai/cusp/toolkit/ceo-snr-leader-chcklst.htmlDecember 01, 2012 - Require that the appropriate office (e.g., Infection Prevention) produce a weekly report of harm, disseminate
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Sensemaking and Learn From Defects for Perinatal Safety | Agency for Healthcare Research and Quality
www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-slides.htmlJuly 01, 2023 - Then, lastly, describe what can be done to minimize patient harm or prevent this safety hazard. … Exercise Please complete the following: List all defects that have the potential to cause to cause harm -
www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module1-presenters-notes.pdfJanuary 12, 2022 - Diagnostic harm, which can result from diagnostic error, is an emerging area of concern in healthcare … safety and risk management literature, as well as care delivery research, demonstrates that diagnostic harm … Organizations and providers need resources to mitigate diagnostic harm, but few tools are currently … families, and • Provide assessment and training tools to support local efforts to reduce diagnostic harm … • These gaps can delay diagnostic processes and in some cases result in serious harm or even death
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/attitudes-beliefs-transcript.pdfApril 01, 2022 - disservice, not only to them, but especially to our patients, because we're there to prevent patient harm … And that also does a lot to prevent adverse events and to mitigate patient harm. … It also identifies the system factors that help prevent harm. … when you use the learning from defects, as I said, it identifies things that limited the potential harm
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/leadership-6.htmlJune 01, 2021 - Patient Safety Watchdog The Leapfrog Group Funded for National Initiative on Preventing Harm From Diagnostic … www.leapfroggroup.org/news-events/patient-safety-watchdog-leapfrog-group-funded-national-initiative-preventing-harm
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Browne_5.pdfJanuary 20, 2008 - patient safety movement seeks to build a culture in which systems mitigate human error and prevent harm … When an error results in harm to a patient, it should be regarded as a consequence rather than cause … The “Swiss Cheese Model” depicting the way systems place barriers designed to prevent harm and create … Immediately following the identification of a near miss or serious event resulting in patient harm, … To do no harm. San Francisco: Jossey Bass; 2005. 3. Reason J.
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National Quality Strategy (pdf file)
www.ahrq.gov/sites/default/files/wysiwyg/NQS_overview_slides-2017.pdfJanuary 01, 2017 - . 11 THE NATIONAL QUALITY STRATEGY PRIORITIES 12 Priority 1: Making care safer by reducing harm … Reduce harm from inappropriate or unnecessary care. 13 Priority 2: Ensuring that each person and … : How It Works The national quality strategy priorities Priority 1: Making care safer by reducing harm -
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/learn/learn-about-cusp-facilitator-guide.pdfMay 01, 2017 - 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 … 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.
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www.ahrq.gov/hai/cusp/modules/apply/ac-cusp.htmlDecember 01, 2012 - 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. … Display statistics that show how the initiative reduces both patient harm and the average cost per occurrence … hospital staff members, which will ultimately increase patient safety and reduce unnecessary expenses and harm
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www.ahrq.gov/hai/cusp/modules/engage/exec-slides.htmlDecember 01, 2012 - 14: The Senior Executive’s Role on the Team Slide 15: Holds Staff Accountable for Reducing Patient Harm … Click to play Return to Contents Slide 15: Holds Staff Accountable for Reducing Patient Harm
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www.ahrq.gov/sites/default/files/publications/files/interimhacrate2013_0.pdfOctober 27, 2014 - Although the precise causes of the decline in patient harm are not fully understood, the increase in … Introduction Much attention has been focused on preventing patient harm since the Institute of Medicine … spotlight on patient safety but also highlighted the fact that making progress to reduce patient harm … Persistent support for research focused on understanding health care harm—why it occurs, what can be … Temporal trends in rates of patient harm resulting from medical care.
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Applying CUSP To Promote Safe Surgery (pdf file)
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/guide-appcusp.pdfDecember 01, 2017 - care system through technical and adaptive work to improve patient safety and eliminate preventable harm … develop lenses to focus on system factors that can negatively impact care and lead to preventable harm … All too often, we assume that patient harm occurs because of inexperience, lack of supervision, or bad … • What do you think can be done to prevent this harm? … You can use quantitative methods (for example, numerically rating risk of harm) or informal methods -
www.ahrq.gov/patient-safety/reports/liability/etchegaray.htmlAugust 01, 2017 - given that no foreseeable improvement in health care delivery will eliminate all errors that seriously harm … to know about medical errors, with virtually all patients wanting to know about errors that directly harm … serious error (i.e., error that causes permanent injury or transient but potentially life-threatening harm … errors, suggesting that clinicians are even less likely to meet patients’ expectations after minor harm … their relationship with the patient may outweigh the benefit to the patient of knowing about minor harm
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module3/module3-assessment-change-readiness-gap-analysis.pptxAugust 25, 2015 - sub-steps will be discussed further on the next few slides. 6 Define a CANDOR Event2 Potential patient harm … Module 3 7 A CANDOR event is defined as an event that involves unexpected harm (physical, emotional … implementation of the CANDOR process in an organization is to tie this definition to the organization’s current harm … White Paper Series: Serious Safety Events: A Focus on Harm Classification: Deviation in Care as Link.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Jones_91.pdfJuly 17, 2008 - Error occurred that reached the patient and required monitoring to confirm that it resulted in no harm … to or resulted in temporary harm to the patient and required Intervention 0.4 0.2 1.4 F Error … occurred that might have contributed to or resulted in temporary harm or required initial or prolonged … 0.0 0.1 0.3 G Error occurred that might have contributed to or resulted in permanent patient harm … (N = 1,851) % (N = 4,260) % (N = 149,978) B (near miss) C - D (reached the patient, no harm
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www.ahrq.gov/hai/cauti-tools/phys-championsgd/appa.htmlOctober 01, 2015 - Infections Preamble and Summary Epidemiology of Invasive Devices and Complications Examples of Patient Harm
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/afib_topicref.pdfJanuary 01, 2020 - Catheter Ablation for Atrial Fibrillation: Topic Refinement - Project ID: CRDT0913 Final Topic Refinement Document Catheter Ablation for Atrial Fibrillation - Project ID: CRDT0913 Date: 05/29/2014 Topic: Catheter Ablation for Atrial Fibrillation – Project ID: CRDT0913 EPC: Pacific Northwest EPC AHRQ Task …
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