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Showing results for "harm".

81. 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.

82. Table 6: Categories of Medication Error Classification | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/resources/match/matchtab6.html
    August 01, 2012 - Error that did not reach the patient NA C Error that reached patient but unlikely to cause harm … Error that reached the patient and could have necessitated monitoring and/or intervention to preclude harm … metoprolol was ordered for patient instead of extended-release E Error that could have caused temporary harm … pressure medication was inadvertently omitted from the orders F Error that could have caused temporary harm … ordered daily when the patient takes it every other day G Error that could have resulted in permanent harm

83. Final Progress Report: Transdisciplinary Learning Lab To Eliminate Patient Harm and Reduce Waste (pdf file)
    www.ahrq.gov/sites/default/files/2025-03/sapirstein-report.pdf
    January 01, 2025 - Learning Lab to Eliminate Patient Harm and Reduce Waste Johns Hopkins Medicine Principal Investigator … Apply SE framework to address a common, preventable harm in the intensive care unit (ICU) 3. … The Causal Loop Model for Susceptibility to Preventable Harm in the ICU. … Managing Data Requirements to Measure ICU Susceptibility to Patient Harm. … Managing data requirements to measure ICU susceptibility to patient harm.

84. 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

85. 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.

86. 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

87. How To Measure Fall Rates and Fall Prevention Practices
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module5/module5_slides_fallprev.pptx
    December 03, 2012 - . ‹#› 48 JAH VAMC Med-Surg Falls with Harm by Quarter per 1000 pt days (Includes all harm … per 1000 pt days JAH VAMC Med-Surg Falls with Harm by Quarter per 1000 pt days (Includes all harm categories … per 1000 pt days JAH VAMC Med-Surg Falls with Harm by Quarter per 1000 pt days (Includes all harm categories … 0 Quarter harm from falls Pilot Unit (5 South) Harm from Falls per 1000 pt days by Quarter JAH VAMC … 0 Quarter harm from falls Pilot Unit (7 North) Harm from Falls per 1000 pt days by Quarter

88. Medications Supplement Dashboard Data 2023 (xls file)
    www.ahrq.gov/sites/default/files/wysiwyg/npsd/Medications_Supplement_Dashboard_Data_2023.xlsx
    January 01, 2023 - (e.g., sustained release instead of immediate release) No Harm 417 95.2% Incorrect dose(s) Harm 967 … 93.9% Incorrect preparation Harm 32 3.1% Incorrect preparation No Harm 993 96.9% Incorrect rate Harm … 72 7.4% Incorrect rate No Harm 904 92.6% Incorrect route of administration Harm 83 9.2% Incorrect … strength or concentration No Harm 467 94.9% Incorrect timing Harm 347 5.7% Incorrect timing No Harm … 5,760 94.3% Multiple Harm 378 12.5% Multiple No Harm 2,635 87.5% Other: Please specify Harm 585 4.5%

89. 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?

90. Learning From Diagnostic Errors | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-psychological-safety-1.html
    September 01, 2023 - define and enumerate diagnostic errors, but we are often reminded by patients and clinicians of the harm … Successful approaches to learn from diagnostic quality and develop strategies to reduce harm from diagnostic

91. 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.

92. 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.

93. New Mental Health Resources From AHRQ | Agency for Healthcare Research and Quality
    www.ahrq.gov/news/mental-health-resources.html
    May 01, 2024 - Month, AHRQ’s Academy for Integrating Behavioral Health and Primary Care is highlighting Integrating Harm … Harm reduction principles and practices prioritize engaging directly with patients with substance use

94. 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

95. 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.

96. 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?        

97. 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.

98. 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

99. 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.

100. 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