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www.cpsi.ahrq.gov/health-literacy/professional-training/shared-decision/workshop/mod1-guide.html
September 01, 2020 - Skip to main content
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Anthony.pdf
January 01, 2005 - and hazards embedded within the structure and process of
care that can potentially cause injury or harm … errors and the use of safety design concepts to prevent or minimize errors by
detecting them before harm … Root cause analysis may also be use to
probe a near-miss mistake, an error is caught before it causes harm
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Wakefield2.pdf
January 01, 2003 - defined as any preventable event that may cause or lead to inappropriate
medication use or patient harm
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/part-i-asc_database_report-rev091721.pdf
January 01, 2020 - Documentation - 2020 SOPS ASC Database
Near-Miss Documentation
When something happens that could
harm … 25th
%ile
Median/
50th
%ile
75th
%ile
90th
%ile Max
When something happens that could harm
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www.cpsi.ahrq.gov/hai/pfp/methods.html
December 01, 2017 - ratios are, with one exception, all below 1.0 makes intuitive sense: it is credible that the rate of harm
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/improve/gap_analysis_tool.docx
November 01, 2019 - and recommend improvement approaches
☐ Perform proactive risk assessments to determine areas in which harm
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www.cpsi.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/management/kit.html
June 01, 2017 - shows key safety indicators such as the number of days since the last “near miss” event or patient harm
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www.cpsi.ahrq.gov/research/findings/factsheets/minority/cbprbrief/index.html
April 01, 2020 - Rural community members' perceptions of harm from medical mistakes: a High Plains Research Network (HPRN
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www.cpsi.ahrq.gov/hai/cauti-tools/archived-webinars/breaking-down-barriers-slides.html
December 01, 2017 - Skip to main content
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/ced-appendix2-comments.xlsx
October 12, 2022 - Appendix 2: CED Compiled Public Comment Themes
Summary_Out of Scope Comments
There were many comments that were outside of the scope of this project in that they addressed the CED process rather including when and how it should be implemented. Multiple comments proposed that AHRQ should undertake a similar exercise …
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www.cpsi.ahrq.gov/teamstepps/webinars/index.html
September 01, 2019 - experiential learning of the TeamSTEPPS key principles on the path toward "zero events of preventable harm
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/topics/advancing-diagnostic-equity.pdf
November 15, 2022 - Advancing Diagnostic Equity Through Clinician Engagement, Community Partnerships, and Connected Care
Advancing Diagnostic Equity Through Clinician
Engagement, Community Partnerships, and Connected
Care
Traber D. Giardina, PhD, MSW1,2 , LeChauncy D. Woodard, MD, MPH3, and
Hardeep Singh, MD, MPH1,2
1Houston Cent…
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www.cpsi.ahrq.gov/patient-safety/settings/hospital/resource/guide/web6.html
December 01, 2017 - Harm reduction.
Meet "where they are."
Patient priorities first.
Relationship-based.
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/invest-in-trust-guide.pdf
May 01, 2021 - their concerns about short-term side
effects, fear about how the vaccine might affect
pregnancy or harm … The vaccine could harm their pregnancy or their potential to become
pregnant.
6. … If you can’t do that, trying to convince them
yourself may do more harm than good.
2. … The six foundations for which they think
there currently is evidence are: 1) Care/harm;
2) Fairness
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/healthitresourcelist.pdf
January 01, 2019 - include a webinar, podcast, and course to teach where health IT can unexpectedly
contribute to patient harm
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4d_combo_psi07-crbsi-bestpractices.pdf
May 20, 2016 - in terms of both morbidity and
financial resources expended.3,4
• CLABSIs not only cause patient harm
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www.cpsi.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-5/slides.html
September 01, 2017 - Slide 35: Annotated Run Chart
Image: Annotated run chart: med-surg falls with harm by quarter per
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/nhguide/4_TK1_T4-Urinalysis_and_UTIs_Improving_Care_Final_0.docx
October 01, 2016 - Tool 4. Training Modules: Urinalysis and UTIs Improving Care
Overview
These training modules are designed to be flexible to meet your needs. Training coordinators can use them individually or combine them to suit the needs of their facility.
Goals and Objectives for Training
The overall goal of training is to learn how…
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/teamstepps/officebasedcare/ts-obc-online-module8.pptx
March 07, 2019 - the end of the shift, it would be better not to announce you're leaving and make a joke that could harm … the end of the shift, it would be better not to announce you're leaving and make a joke that could harm
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/patientsafety/2017qdr-patsafchartbook.pdf
October 01, 2018 - Making care safer by reducing harm caused in the delivery of care.
2. … admissions and
readmissions, reduce the incidence of adverse healthcare-associated conditions, and reduce harm … This chartbook focuses on adverse healthcare-associated conditions and harm from care. … includes the use of invasive devices and procedures, increasing patients’ risk
for infection and other harm … Adverse Drug Events
• An adverse drug event (ADE) is an injury—including physical harm, mental harm,