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Total Results: 520 records

Showing results for "harm".

1. NPSD Dashboards | Agency for Healthcare Research and Quality
   www.cpsi.ahrq.gov/npsd/data/dashboard/index.html
   October 01, 2023 - The dashboard charts detail event type, report type by event type, extent of harm by event type, event … type by extent of harm, and extent of harm.   … Falls Dashboard Details the extent of harm due to falls, the presence of fall assistance, presence … of fall assistance by patient harm, type of fall injury, and fall location.     … to the patient, type of incorrect dose, type of incorrect dose by residual harm to the patient, stage

2. VHA's Journey to High Reliability: Advancing Toward Zero Harm and Becoming a Learning Health System
   www.cpsi.ahrq.gov/sites/default/files/wysiwyg/action-alliance/high-reliability-journey-slides.pptx
   September 26, 2023 - VHA's Journey to High Reliability: Advancing Toward Zero Harm and Becoming a Learning Health System … September 26, 2023 Pre-Decisional Deliberative Document Internal VA Use Only Advancing Toward Zero Harm … VA Use Only ‹#› 2 VHA’s Journey to High Reliability Foundation Pivotal studies on patient harm … environments Fewer than anticipated accidents or events of harm An “accident or event of harm” could … Culture of Safety Safety values and practices are used to prevent harm and learn from mistakes.

3. NPSD Data Spotlight: Patterns of Fall Interventions (pdf file)
   www.cpsi.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-patterns-fall-interventions.pdf
   September 01, 2023 - For this analysis, reported EXTENT of HARM were further dichotomized as either No harm or Harm (i.e … ., Mild harm, Moderate harm, Severe harm or Death). … Specifically, we examined the no-harm rate, or the percentage of falls that resulted in no harm to … harm to the patient. … Events Resulting in No Harm to Patient No-harm Rate (%) Low bed, Items in reach, Visible

4. Implementation Guide for the CANDOR Process | Agency for Healthcare Research and Quality
   www.cpsi.ahrq.gov/patient-safety/settings/hospital/candor/impguide.html
   August 01, 2022 - report, To Err Is Human: Building a Safer Health System , the problems associated with injury and harm … the United States provides some of the best health care in the world, unsafe health care processes harm … This statistic represents only one type of patient harm that results during the delivery of patient care … A CANDOR event is defined as an event that involves unexpected harm (physical, emotional, or financial … A CANDOR event is defined as an event that involves unexpected harm (physical, emotional, or financial

5. Module 1: An Overview of the CANDOR Process | Agency for Healthcare Research and Quality
   www.cpsi.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes1.html
   August 01, 2022 - A CANDOR event is an event that involves unexpected patient harm. … The unexpected harm can be physical, emotional, or financial. … Care for the caregivers is frequently absent in the traditional response to harm. … The CANDOR process promotes the value of disseminating lessons learned and solutions to prevent harm … events, and offering compensation for the patient’s harm, when appropriate.

6. Making the Case That Improving Antibiotic Use is a Patient Safety Issue | Agency for Healthcare Research and Quality
   www.cpsi.ahrq.gov/antibiotic-use/acute-care/safety/patient-safety.html
   November 01, 2019 - After viewing or presenting this presentation viewers will be able to— Explain the potential harm … associated with antibiotic use Recognize that patient harm is often preventable Recognize that change … require a focus on systems, not individuals Recognize the importance of diverse input to prevent harm

7. Safer Together: A National Action Plan to Advance Patient Safety | Agency for Healthcare Research and Quality
   www.cpsi.ahrq.gov/patient-safety/reports/safer-together.html
   November 01, 2022 - 2018 by the Institute for Healthcare Improvement and committed to achieving safer care and reducing harm … Though U.S. researchers have identified many evidence-based, effective best practices for harm reduction … Reducing preventable harm requires a total systems approach: a coordinated, proactive strategy in which … precondition to advancing patient safety with a unified, total systems-based approach to eliminate harm

8. Silence A Commentary | Agency for Healthcare Research and Quality
   www.cpsi.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 … . 5 I believe there is a fifth desire for some patients and families after harm has occurred, and it … Instead of letting fear drive the actions and behaviors after harm, it is the mindset of courage and … RCA: Improving Root Cause analyses and Actions to Prevent Harm.

9. Create a Culture of Safety Around Antibiotic Prescribing | Agency for Healthcare Research and Quality
   www.cpsi.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

10. Develop a Culture of Safety Around Antibiotic Prescribing | Agency for Healthcare Research and Quality
    www.cpsi.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

11. Preventing Falls in Hospitals
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module1/module1_slides_fallprev.pptx
    June 16, 2017 - Falls harm patients. 30% to 51% of falls result in injury. … 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

12. Module 4: Event Reporting, Event Investigation and Analysis | Agency for Healthcare Research and Quality
    www.cpsi.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 … 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. … Identification of innovative solutions to prevent similar harm events and related hazardous behaviors

13. Table 6: Categories of Medication Error Classification | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/patient-safety/settings/hospital/match/table-6.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

14. When It Comes to High-Quality Healthcare, Diagnostic Safety Tops the List | Agency for Healthcare Research and Quality
    www.cpsi.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.

15. Module 7: Resolution | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes7.html
    August 01, 2022 - Following patient harm events, the patient and/or family might sue the caregiver and/or organization, … Creating a learning organization in which patient harm is reduced through ongoing learning from patient … When harm occurs, patients often express the desire to protect others from future events. … Becoming a learning organization supports the goal of preventing similar harm to patients in the future … patients and families supports the patient’s and/or family’s need for an explanation of the patient harm

16. Gap Analysis Facilitator's Guide: Appendix B | Agency for Healthcare Research and Quality
    www.cpsi.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?

17. Gap Analysis Facilitator's Guide: Appendix C | Agency for Healthcare Research and Quality
    www.cpsi.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?        

18. Appropriate Disclosure to a Patient: Video | Agency for Healthcare Research and Quality
    www.cpsi.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.

19. Inappropriate Disclosure to a Patient: Video | Agency for Healthcare Research and Quality
    www.cpsi.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.

20. Module 5: PowerPoint Presentation
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/visual/visual-mgmt.pptx
    May 01, 2017 - Ambulatory Surgery Management Practices for Sustainability Key outcome measures Days since last harm … 221 Werner  111 Carletta  221 Safety training chart Date Revised Number of Procedures since last harm … Date Opportunity Action Results Smith ASC Excellence in Safety: No Harm … Keep track of count of procedures since last harm incident each day update the board. … ###1 Ardella Ruffo  A16:00 ####4 Safety Check 4 5 6 7 Our Surgery Center “Excellence in Safety: No Harm