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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/resources/asc-survey.docx
June 06, 2018 - .
► Patient safety is the prevention of harm resulting from the processes of health care delivery. … prevention includes reducing mistakes, errors, incidents, events, or problems that lead to patient harm … 2
3
4
5
9
SECTION D: Near-Miss Documentation
► When something happens that could harm
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/2019-nhsops-dbreport-partii.pdf
January 01, 2019 - When staff report something that could harm a resident, someone takes care of
it. … When staff report something that could harm a resident, someone takes care of it. … Staff tell someone if they see something that might harm a resident. … In this nursing home, we discuss ways to keep residents safe from harm. … In this nursing home, we discuss ways to keep residents safe from harm.
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/nhguide/6_TK1_T2-Talking_with_Residents_Family_Members_Final.docx
October 01, 2016 - .
· Unneeded antibiotics can do more harm than good.
· Before taking an antibiotic, it is important to … understand how antibiotics could harm or hurt your family member.
· Although we cannot be certain that … Decrease the likelihood that residents experience any harm, including C. diff infections and antibiotic
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www.qualitymeasures.ahrq.gov/antibiotic-use/long-term-care/safety/improve-use.html
June 01, 2021 - Recognize that patient harm is largely preventable.
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/resources/asc-survey.pdf
June 06, 2018 - ► Patient safety is the prevention of harm resulting from the processes of health care delivery. … prevention
includes reducing mistakes, errors, incidents, events, or problems that lead to patient harm … 2
SECTION D: Near-Miss Documentation
► When something happens that could harm
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/sops-nurse-home-items-06-16-21.pdf
January 01, 2000 - When staff report something that could harm a resident, someone takes care of it.
B5. … Staff tell someone if they see something that might harm a resident.
B8. … In this nursing home, we discuss ways to keep residents safe from harm.
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www.qualitymeasures.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/assessment.html
July 01, 2023 - Include any relevant examples that you observed/were concerned about involving patient harm that could … Please describe what you think can be done to prevent or minimize this harm.
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/nursing-home/2016/nhsurv16-pt2.pdf
January 01, 2016 - When staff report something that could harm a resident, someone takes care of
it. … Staff tell someone if they see something that might harm a
resident. … In this nursing home, we discuss ways to keep residents safe
from harm. … Staff tell someone if they see something that might harm a resident. … In this nursing home, we discuss ways to keep residents safe from harm.
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/graber-summit2016.pdf
January 01, 2017 - Diagnostic errors are a significant but
underappreciated challenge to health care quality
and harm … ”
• Add these slides if Victor doesn’t cover
them
Diagnostic Error
Error-related
Harm
40,000 … Number 26
Diagnostic errors are a significant but underappreciated challenge to health care quality and harm
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www.qualitymeasures.ahrq.gov/research/findings/making-healthcare-safer/comparison.html
September 01, 2022 - Healthcare Safer report, published in 2020, includes 47 evidence-based patient safety practices in selected harm … It includes evidence for more specific harm areas than the preceding reports.
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/visual/visual-mgmt-facnotes.docx
May 01, 2017 - The top center has key measures including number of procedures since last harm event and near miss. … To start with, you can track key outcome measures, including days since last harm event and days since … Agree on a clear definition of both harm and “near miss” so that your tracking is consistent over time … You may choose to start with only a couple of items, such as a measure of last harm together with a visual
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.doc
November 15, 2019 - error, mistake, incident, accident, or deviation, regardless of whether or not it results in patient harm … When a mistake is made, but has no potential to harm the patient, how often is this reported? … When a mistake is made that could harm the patient, but does not, how often is this reported?
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www.qualitymeasures.ahrq.gov/npsd/data/dashboard/generic.html
September 01, 2023 - examines their location and contributing factors, as well as prevention actions and extent of residual harm
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.pdf
November 18, 2019 - error, mistake, incident, accident, or deviation,
regardless of whether or not it results in patient harm … When a mistake is made, but has no potential to harm the patient, how
often is this reported? … When a mistake is made that could harm the patient, but does not,
how often is this reported?
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/improve/behavior-change-slides.pptx
November 01, 2019 - Drivers of Suboptimal Antibiotic Prescribing
Fear of inadequate antibiotic coverage leading to patient harm … (or legal harm)
Fear of judgment by peers and superiors (deviation from the norm)
Not wanting to change … Drivers of Suboptimal Antibiotic Prescribing
Fear of inadequate antibiotic coverage leading to patient harm … (or legal harm)
Fear of judgment by peers and superiors (deviation from the norm)
Not wanting to change
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www.qualitymeasures.ahrq.gov/news/newsroom/press-releases/significant-patient-safety-improvement.html
July 01, 2022 - Research and Quality (AHRQ) shows that rates of in-hospital adverse events for healthcare related patient harm … Adverse events are often defined as physical or psychological harm caused by a person’s interaction with
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/resources/tools/improve/discussion-guide.docx
March 01, 2017 - results are useful for measuring organizational conditions that can lead to adverse events and resident harm … about the facility’s strengths and areas for improvement.
· Start the meeting with a story of resident harm … and spend a few minutes talking about your feelings associated with that harm.
· Discussion questions
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/2023-SOPS-Nursing-Home-DB-Part-II.pdf
January 01, 2023 - (Item B5)
84% 80%
Staff tell someone if they see something that might harm a resident. … (Item B6) 89% 85%
In this nursing home, we discuss ways to keep residents safe from harm. … (Item B5)
83%
Staff tell someone if they see something that might harm a resident. … (Item B5)
79% 89%
Staff tell someone if they see something that might harm a resident. … (Item B6) 85% 89%
In this nursing home, we discuss ways to keep residents safe from harm.
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/data-change-notes.docx
April 01, 2022 - This is particularly impactful since the goal for harm is zero. … On this particular patient harm index, the current year is in patterned blue and the past year is in … This type of data display or harm index could be used for reporting to any group, even hospital boards … , as it is understandable and drives home how many patients are sustaining harm from potentially avoidable … processes provides the opportunity to sustain the gains and continue reaching for the goal of zero harm
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www.qualitymeasures.ahrq.gov/prevention/chronic-care/decision/research-centers/index.html
October 01, 2018 - At the same time, other people get services that have no benefit or even cause harm.