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Showing results for "harm".

61. 114-Mrsa-Prevention-Learning-From-Defects (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/114-mrsa-prevention-learning-from-defects.docx
    October 01, 2024 - 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. … Positive contributing factors are factors that limited the impact of harm for patients.

62. Prologue—Volume 2—Systems Thinking and Patient Safety (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Schyve.pdf
    June 02, 2025 - This should come as no surprise, given that “first, do no harm” has been the ethical watchword throughout … of techniques that we might employ to bring reality closer to the ideal of doing no (preventable) harm … The realization of the magnitude of this failure and that there are potential routes to reducing harm … Even today, preventable patient harm is too often associated with error—usually human error—both within … How can we intervene to prevent harm from unintended consequences?

63. Gap Analysis Facilitator's Guide: Appendix C | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/apc.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?        

64. Antibiotic-Targets-Facilitator-Guide (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/antibiotic-targets-facilitator-guide.docx
    June 01, 2021 - Slide 3 Recognizing Potential Harm SAY: Before we move forward, let’s take a moment to talk about … the potential for patient or resident harm. … Slide 4 Examples of Potential Harm SAY: A few examples of potential harm related to antibiotic use … Moment 4 may have caused the most notable harm in this case. … This type of problem solving generally does not help prevent future harm from occurring.

65. Improving the Value of Patient Safety Reporting Systems (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Pronovost_95.pdf
    June 12, 2008 - While there is wide variation relative to how harm is classified,16, 17 we believe harm can be biological … in the harm classification section. … That is, the odds that an event will result in harm. … ) to weakest (least likely to reduce harm). … A weaker intervention would mitigate harm.

66. Final Progress Report: Patient Safety in Hospice Care (pdf file)
    www.ahrq.gov/sites/default/files/2024-10/smucker-report.pdf
    January 01, 2024 - for preventing patient safety incidents or for detecting them early to mitigate the potential for harm … hospice care have the characteristics (readily identifiable, preventable, and severe potential for harm … Injuries from falls: Common contributing factors for falls leading to harm included: • Patients living … The harm to the patient is obvious, but emotional harm to family, caregivers, and hospice team members … Harm ranged from temporary oversedation to possible hastening of death in an actively dying patient.

67. Measure Dx: A Resource To Identify, Analyze, and Learn From Diagnostic Safety Events | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/tools/measure-dx.html
    March 01, 2024 - From Diagnostic Safety Events Diagnostic errors are major contributors to patient harm … can be used by any healthcare organization interested in promoting diagnostic excellence and reducing harm

68. Final Progress Report: Demonstration Project To Refine, Automate and Test a Novel Emergency Department Trigger Tool (pdf file)
    www.ahrq.gov/sites/default/files/2025-02/griffey-report.pdf
    January 01, 2025 - Trigger distribution data allows for population estimates of harm. … Otherwise, in-depth reviews identify any AEs and their level of harm. … This allows reviewers to focus their reviews on detecting harm. … and non-harm events in their EDs for quality improvement purposes. … Preventable harm: getting the measure right. BMJ 2019;366l4611. 62.

69. Making Healthcare Safer III: Structured Abstract | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/findings/making-healthcare-safer/mhs3/abstract.html
    March 01, 2020 - Identification, selection, and prioritization of harm area topics. … sensitive events, procedural events, and diagnostic errors; and the report covers 47 PSPs in 17 specific harm … While the team was going through the process of selecting PSPs to address specific harm areas, it became … that a wide range of factors impact the effectiveness of PSPs with respect to their ability to prevent harm

70. Tool: Cross-Monitoring | Agency for Healthcare Research and Quality
    www.ahrq.gov/teamstepps-program/curriculum/situation/tools/monitoring.html
    June 01, 2023 - It allows individuals and teams to take steps to correct the issue before harm or injury to the patient … Cross-monitoring is a harm and error reduction strategy that involves: Monitoring actions of other

71. Final Progress Report: APPLIED STRATEGIES FOR IMPROVING PATIENT SAFETY (ASIPS) (pdf file)
    www.ahrq.gov/sites/default/files/2024-02/pace-report.pdf
    January 01, 2024 - We also analyzed our reports from harm. … too early to tell if harm occurred. … Analysis of the taxonomy harm codes revealed that 3% suffered some degree of harm and 26% experienced … Types of harm described by community members included emotional, financial, and physical harm. … Mis-timed procedures or delays in therapy were also associated with clinical harm.

72. The Comprehensive Unit-based Safety Program (CUSP) for MRSA Prevention | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/mrsa-prevention/surgery/cusp-mrsa-prevention.html
    April 01, 2025 - 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 … 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 … Sustainability CUSP encourages—and relies on—on frontline staff to speak up if they observe preventable harm

73. New York City Uses AHRQ Patient Safety Culture Survey to Reduce Patient Harm | Agency for Healthcare Research and Quality
    www.ahrq.gov/news/newsroom/case-studies/cquips0901.html
    October 01, 2014 - New York City Uses AHRQ Patient Safety Culture Survey to Reduce Patient Harm Search All Impact Case … multi-year campaign to improve the culture of safety across the organization and reduce chances for patient harm

74. Overview of the National Action Alliance for Patient and Workforce Safety | Agency for Healthcare Research and Quality
    www.ahrq.gov/action-alliance/overview/index.html
    October 01, 2024 - Working together, the National Action Alliance catalyzes change by applying known harm reduction strategies … that healthcare is not safe until it is safe for all, the National Action Alliance works to address harm … The National Action Alliance envisions a future with safe care everywhere and zero preventable harm … partners in the healthcare community collectively achieve a shared goal of eliminating preventable harm

75. Resident Physicians as Champions in Preventing Device-Associated Infections | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/cauti-tools/phys-championsgd/index.html
    October 01, 2015 - Infections Preamble and Summary Epidemiology of Invasive Devices and Complications Examples of Patient Harm … Information Preamble Summary Epidemiology of Invasive Devices and Complications Examples of Patient Harm

76. An Overview of the CANDOR Process
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4/module4-event-reporting-investigation-analysis.pptx
    September 10, 2015 - Do they believe the organization is aware of all the patient harm events? … Protects patients from future harm events. … to prevent future harm events.   … The organization should have a mechanism in place to address anonymous reports of harm events. … Event Near Miss Unsafe Conditions Actual Harm to Patient Potential Harm to Patient One of the hallmarks

77. Person-Centered Preventive Healthcare: Gathering Stakeholder Input on Evidence and Implementation | Agency for Healthcare Research and Quality
    www.ahrq.gov/ncepcr/research/disseminating-evidence/pcph.html
    September 01, 2024 - At the same time, other people get CPS that have no benefit or even cause harm. … Stopping the delivery of CPS that may cause more harm than benefit.

78. Create a Culture of Safety Around Antibiotic Prescribing | Agency for Healthcare Research and Quality
    www.ahrq.gov/antibiotic-use/long-term-care/safety/index.html
    January 01, 2024 - be encouraged to understand both the benefits and risks of antibiotic use and be engaged in reducing harm … Reducing harm often requires changes in thinking and behavior. … providers in creating a safety culture that values appropriate antibiotic prescribing and takes action when harm

79. Develop a Culture of Safety Around Antibiotic Prescribing | Agency for Healthcare Research and Quality
    www.ahrq.gov/antibiotic-use/acute-care/safety/index.html
    June 01, 2021 - be encouraged to understand both the benefits and risks of antibiotic use and be engaged in reducing harm … Reducing harm often requires a change in thinking and behavior. … providers in creating a safety culture that values appropriate antibiotic prescribing and takes action when harm

80. PowerPoint Presentation
    www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/antibiotic-targets-slides.pptx
    June 01, 2021 - science of safety Improve teamwork and communication Recognize current practices that may lead to patient harm … Steps for Improving the Culture of Patient Safety 3 3 Identifying Targets 3 Recognizing Potential Harm … Describe what you think can be done to prevent this from happening How Can You Identify Potential Harm … problem solving Solves one problem in one particular instance Generally does not help prevent future harm … Start with a problem or potential harm that is easy to fix.