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Total Results: 2,181 records

Showing results for "harm".

81. Intravenous Infusion Safety Initiative: Collaboration, Evidence-Based Best Practices, and “Smart” Technology Help Avert High-Risk Adverse Drug Events and Improve Patient Outcomes (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Maddox_38.pdf
    March 26, 2008 - Introduction “First, do no harm” is the ethical imperative for every patient safety effort. … Analysis of Prevented ADEs and Associated Harm In July 2003, an innovative harm-assessment tool was … innovative tool allowed us to assess the extent of harm averted by the system. … The harm and costs averted using this technology are substantial. … Application of the IV Medication Harm Index to assess the nature of harm averted by “smart” infusion

82. Making Effective Changes in Antibiotic Decision Making (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/changes-facilitator-guide.pdf
    November 01, 2019 - Identify interventions to reduce future harm associated with unnecessary antibiotic use 3. … Using one of the areas of harm, acute kidney injury from unnecessary vancomycin, let’s consider how … as well as those that had the potential to cause harm. … Positive contributing factors are factors that limited the impact of harm. … ensure that solutions are implemented and harm is reduced.

83. Pediatric Diagnostic Safety Research and Initiatives Across the Care Continuum | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-pediatric-safety-3.html
    August 01, 2023 - addition, leading organizations in pediatric safety have begun efforts to educate about, study, and reduce harm … Care . 60 Nonetheless, MDOs occur even in this setting designed to identify new diagnoses well before harm … diagnoses, rarer and atypical presentations may go unrecognized, exposing patients to more risk of harm … visits. 81 Overall, the existing literature suggests that identifying, learning from, and reducing harm … these observations into effective and feasible interventions that can prevent misdiagnosis-related harm

84. Resources by the CMS Patient Safety Structural Measure Domains | Agency for Healthcare Research and Quality
    www.ahrq.gov/action-alliance/resources/measure-domains.html
    April 01, 2025 - Domain 1: Leadership Commitment to Eliminating Preventable Harm: Executive leadership oversees organizational … Domain 2: Strategic Planning and Organizational Policy: Commitment to “zero preventable harm.” … Contents Domain 1: Leadership Commitment to Eliminating Preventable Harm . … Domain 1: Leadership Commitment to Eliminating Preventable Harm Commitment to Advance Patient and Workforce … tools for data entry and analysis and strategic planning to inform unit-based interventions to reduce harm

85. Module 5: Response and Disclosure | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/notes.html
    August 01, 2022 - designated communicator will engage in followup communication with the patient and/or family about the harm … The patient and/or family have a reasonable expectation to be informed when a harm event has occurred … Patients and families can be engaged as partners in organizational discussions about harm prevention … training appropriate individuals to communicate with patients, families, and staff after a patient harm … appropriate skills and attitudes to communicate with patients, families, and staff after a patient harm

86. Learning-From-Antibiotic-Adverse (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/learning-from-antibiotic-adverse.docx
    June 01, 2021 - any event or situation 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 increase the risk of harm. We want to change these. … Positive contributing factors limit the impact of harm. We want to keep these.

87. When It Comes to High-Quality Healthcare, Diagnostic Safety Tops the List | Agency for Healthcare Research and Quality
    www.ahrq.gov/news/blog/ahrqviews/diagnostic-safety-tops-the-list.html
    March 01, 2024 - Among those patients, about 18 percent of errors caused temporary harm, permanent harm, or death. … errors that persist throughout all care settings, involve common and rare diseases, and continue to harm … They underscore the imperative to mitigate diagnostic errors and harm.

88. Making the Case That Improving Antibiotic Use Is a Patient Safety Issue (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/patient-safety-facilitator-guide.pdf
    November 01, 2019 - SAY: By the end of this presentation, participants will be able to:  Explain the potential harm … associated with antibiotic use  Recognize that patient harm is often preventable  Recognize … Slide 4 Antibiotic-Associated Adverse Events SAY: All antibiotics have the potential to harm … other hospitals with antibiotic-associated adverse events, and we may not always be aware of the harm … Regardless of whether antibiotics are necessary or not, they can be associated with harm.

89. PowerPoint Presentation
    www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/antibiotic-patient-safety-slides.pptx
    June 01, 2021 - Safety 1 Objectives Discuss the potential harms associated with antibiotic use Recognize that patient harm … Strive to reduce preventable harm by identifying problems that cause harm to residents. … Recognize current practices that may lead to patient harm. … Create independent checks to reduce potential harm. … Strive to eliminate preventable harm!

90. Communication and Optimal Resolution (CANDOR) | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/index.html
    August 01, 2022 - practitioners can use to respond in a timely, thorough, and just way when unexpected events cause patient harm … A traditional approach when unexpected harm occurs often follows a "deny-and-defend" strategy, providing

91. Final Progress Report: Utility of Predictive Systems in Diagnostic Errors (UPSIDE) (pdf file)
    www.ahrq.gov/sites/default/files/2025-02/auerbach-report.pdf
    January 01, 2025 - Errors contributed to temporary harm, permanent harm, or death in 436 (17.8% of patients, 95% CI 15.9% … For each case with an error, we assessed the extent of the error's contribution to patient harm using … the NCC-MERP scale, which provides explicit definitions of harm (e.g., considering an error to have … was judged to have contributed to temporary harm, permanent harm, or death in 77.1% (95% CI 72.3%-81.9% … For instance, determining the potential for patient harm based on the timing of test results and the

92. IV. Evaluation Aims, Methods, and Results | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/reports/hotline/eval4.html
    May 01, 2016 - scale, and duration of harm. … , or duration of harm. … Duration of Harm No harm 6 N/A (no harm) Mild harm 12 <1 year: 8 ≥1 year: … 0 Unknown: 4 Moderate harm 5 <1 year: 3 ≥1 year: 1 Unknown: 1 Severe harm … Unsafe condition 8 N/A (no harm) Service complaint 4 N/A (no harm) Unclassified

93. Acute Care Learning From Defects
    www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/changes-slides.pptx
    November 01, 2019 - Identify relevant factors that could improve antibiotic use Identify interventions to reduce future harm … 10 Antibiotic-related adverse events are events that either caused harm or had the potential to cause … harm. … patient (want to change these) Positive contributing factors – Factors that limited the impact of harm … Work with all relevant team members to determine solutions to prevent future harm.

94. Learning From Defects Through Sensemaking: Facilitator Notes | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-fac-notes.html
    December 01, 2017 - A defect can be a specific harm to a patient. … What can you do to prevent this harm or SSI? … Ask: Can you give an example of a patient harm? … Ask: Did the factor increase the harm or the risk for harm or decrease it? … What can I do to prevent that harm?

95. Staff-Safety-Assessment (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module2/staff-safety-assessment.docx
    March 01, 2017 - Modules Staff Safety Assessment Purpose: To tap into your experience to determine risks that could harm … You will need details to understand how you can prevent harm. … Please describe what you think can be done to prevent or minimize this harm. 16-0003-03-EF AHRQ Pub

96. National Action Alliance Webinar June 18, 2024: Empowering Patient Voice in Safety Strategies (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/action-alliance-webinar-june-2024.pdf
    January 01, 2024 - Way Safer Together Team of Teams Key Factors • Relentless Pursuit of the Vision of Zero Harm … then North America Solutions for Patient Safety OUR MISSION: Working together to eliminate serious harm … 1,627 HAC Teams Support & Commitment from 140+ Organizational Executives The SPS Journey Toward Zero Harm … • Receive assessment and training tools to support local efforts to reduce diagnostic harm. … Pictures Collaboration: Ohio and then North America Children’s Hospitals The SPS Journey Toward Zero Harm

97. Learndefects (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/learndefects.doc
    June 02, 2025 - 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. … of harm) to the incident?

98. Inappropriate Disclosure to a Patient: Video | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/videos/inapp-disclosure.html
    August 01, 2022 - practitioners can use to respond in a timely, thorough, and just way when unexpected events cause patient harm … This video demonstrates an example of inappropriate disclosure of harm to a patient.

99. Appropriate Disclosure to a Patient: Video | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/videos/app-disclosure.html
    August 01, 2022 - practitioners can use to respond in a timely, thorough, and just way when unexpected events cause patient harm … This video demonstrates an example of appropriate disclosure of harm to a patient.

100. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/grand-rounds-presentation-slides.pptx
     January 01, 2014 - Some organizations struggle to improve the way they and their care teams respond to medical harm. … The CANDOR process aims to change that. 1 Do Less Harm Video 2 Module 1 To get started, let’s watch … Video: Do Less Harm 2 Presentation Goals Highlight the gap between optimal response to medical injury … It is about reducing HARM. Ask what is responsible…not who is responsible. … An understanding of the changes that have been made to prevent harm to another patient.