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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4k_combo_psi14-dehiscence-bestpractices.pdf
May 20, 2016 - • Not only does postoperative wound dehiscence cause patient harm, it also significantly
increases
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www.qualitymeasures.ahrq.gov/topics/antimicrobial-stewardship.html
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/pf-engagement-facilitator-guide.pdf
May 01, 2017 - investigate and analyze it (e.g., a root cause
analysis may be conducted) to determine
whether patient harm
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/health-literacy/professional-training/training-for-health-care-professionals.pdf
January 01, 2014 - Assistants,
Nurse, or other clinical staff
Stop the line (i.e., halt any activity that could
cause harm
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-195-fullreport.pdf
December 17, 2019 - guidelines support the use
of CT imaging in children only when clinically indicated, decreasing the risk of harm … have not been directly
studied but can be implied from the literature that describes the potential harm
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www.qualitymeasures.ahrq.gov/hai/cauti-tools/archived-webinars/cauti-sustainability-slides.html
December 01, 2017 - What steps can you do to prevent this harm? … By either preventing the mistake, making the mistake visible or mitigating the harm
Talk about administering
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www.qualitymeasures.ahrq.gov/patient-safety/patients-families/patient-family-engagement/index.html
April 01, 2018 - practitioners can use to respond in a timely, thorough, and just way when unexpected events cause patient harm
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospitalsurvey2-items.pdf
August 01, 2019 - Hospital Survey on Patient Safety Culture Version 2.0: Composites and Items
SOPSTM Hospital Survey
Items and Composite Measures
Version: 2.0
Language: English
Notes
• For more information on getting started, selecting a sample, determining data collection
methods, establishing data collection procedures, co…
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www.qualitymeasures.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/guide.html
March 01, 2017 - Leadership and staff perceptions of resident harms such as CAUTIs or falls, and staff harm such as a … support for improving performance from clinical decision makers is key to helping your facility reduce harm … Toolkit Modules provides a team-based approach to identifying factors that contributed to resident harm … causes for antibiotic overuse in long-term care. 12 , 13 Moreover, antibiotics can lead to resident harm
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www.qualitymeasures.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/hais/index.html
June 01, 2018 - practices that should be universally used in applicable clinical care settings to reduce the risk of harm
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/sustainability/sustaining-guide.pdf
March 01, 2017 - Leadership and staff perceptions of
resident harms such as CAUTIs or falls, and staff harm such as a
-
www.qualitymeasures.ahrq.gov/hai/quality/tools/cauti-ltc/modules/sustainability/guide.html
March 01, 2017 - Leadership and staff perceptions of resident harms such as CAUTIs or falls, and staff harm such as a
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/2019-pharmacy-sops-database-report-parti-rev091721.pdf
January 01, 2019 - documented
(in writing OR tracked electronically)
D1 When a mistake reaches the patient
and could cause harm … Rarely
1%
Never
1%
94% Positive
D2 When a mistake reaches the patient
but has no potential to harm … When a mistake reaches the patient and could cause harm
but does not, how often is it documented? … When a mistake reaches the patient but has no potential
to harm the patient, how often is it documented
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www.qualitymeasures.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module3/mod3-facguide.html
March 01, 2017 - choices should be emphasized more than the outcome of the choices, which may or may not have resulted in harm … director of nursing, who recognized that this mistake was an opportunity to learn, and not an intentional harm
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/affinity-details-coping-staff-challenges.pdf
September 16, 2020 - No harm, no fowl.”
• Stacey Greenway recognizes that transparency with staff is key.
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/pharyngitis-slides.pptx
September 01, 2022 - particularly children, remain asymptomatically colonized with this organism, and this does not pose any known harm
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/03-ASC-webcast-2023-0509-hare.pdf
January 01, 2023 - Staffing, Work Pressure, & Pace 74%
27
Near-Miss Documentation
When something happens that could harm
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/implementing-guide.pdf
March 01, 2017 - professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules.html#module5
and staff harm … support for improving performance from clinical decision
makers is key to helping your facility reduce harm … Toolkit Modules provides a team-based
approach to identifying factors that contributed to resident harm … leading causes for antibiotic overuse in long-term
care.12,13 Moreover, antibiotics can lead to resident harm
-
www.qualitymeasures.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/implementation-guide/guide-overview.html
May 01, 2017 - errors are treated as an opportunity to learn about root causes and prevent future errors and risks of harm
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/brady-summit2016-breakout.pdf
September 28, 2016 - Breakout Session: Use of Data and Measurement in Improving Diagnostic Safety
Breakout Session:
Use of Data and Measurement in
Improving Diagnostic Safety
Jeffrey Brady, MD, MPH
Director, Center for Quality Improvement and Patient Safety
AHRQ Research Summit on Diagnostic Safety
September 28, 2016
Discussant…