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Showing results for "harms".
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www.ahrq.gov/npsd/data/dashboard/index.htmlSeptember 01, 2024 - NPSD Dashboards The Agency for Healthcare Research and Quality (AHRQ) presents the dashboards of patient safety data received for analysis and publication in the Network of Patient Safety Databases (NPSD). The NPSD dashboards were initially published in June 2019 and were based on more than 1.1 million records …
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www.ahrq.gov/patient-safety/reports/liability/silence.htmlAugust 01, 2017 - Advances in Patient Safety and Medical Liability Silence A Commentary Previous Page Next Page Table of Contents Advances in Patient Safety and Medical Liability Preface Acknowledgments Prologue Silence A Commentary Reforming the Medical Liability System in Massachusetts: Communication, Apo…
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www.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-fac-notes.htmlDecember 01, 2017 - Patient harms often have defect(s) at each of these layers.
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www.ahrq.gov/patient-safety/reports/hotline/eval4.htmlMay 01, 2016 - t When a reported event described multiple harms, the physician classified the event according to the
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects_facnotes.docxDecember 01, 2017 - Patient harms often have defect(s) at each of these layers.
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www.ahrq.gov/hai/tools/mvp/modules/cusp/science-of-safety-fac-guide.htmlFebruary 01, 2017 - Look at each of these system factors and consider how each can carry a defect that leads to patient harms
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Learn From Defects Tool (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/tools/applying-cusp/learn_from_defects.docxDecember 01, 2017 - Learn From Defects Tool AHRQ Safety Program for Surgery Learn From Defects Tool – Perioperative Setting What is a defect? A defect is any event or situation that you don’t want to repeat. This could include an incident that caused patient harm or put patients at risk for harm, such as a patient fall. Problem statem… -
www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes1.htmlAugust 01, 2022 - Module 1: An Overview of the CANDOR Process AHRQ Communication and Optimal Resolution Toolkit Facilitator Notes Say: The CANDOR Toolkit is composed of eight distinct modules that can be used to teach users about the CANDOR process. Module 1 provides an overview of the steps to implement the CANDOR…
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Learning-Antibiotic-Adverse-Events-Form (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/learning-antibiotic-adverse-events-form.docxNovember 01, 2019 - AHRQ Safety Program for Improving Antibiotic Use Learning From Antibiotic-Associated Adverse Events An antibiotic-related adverse event is any event or situation involving the prescription or administration of antibiotics that you would not want to happen again because it either caused your patient harm … -
www.ahrq.gov/npsd/data/dashboard/info.htmlJune 01, 2019 - Dashboard Information NPSD Dashboards display data that follow the Common Formats for Event Reporting – Hospital Version (CFER-H) definitions of Adverse Events, i.e., the Common Formats Event Descriptions. There are 10 CFER-H modules: one Generic module applies to all reported events, and nine event-specific mo…
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Final Progress Report: Toward safer opioid prescribing for chronic pain in high risk populations (pdf file)
www.ahrq.gov/sites/default/files/2024-01/robinson-papp-report.pdfJanuary 01, 2024 - Evaluate risk factors for opioid-related harms. Consider offering naloxone. 9. … some already had high levels of adherence at baseline, (e.g., assessment for opioid related risks/harms -
www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-cognitive-load1.htmlMay 01, 2024 - Cognitive Load Theory and Its Impact on Diagnostic Accuracy Introduction to Diagnostic Errors Previous Page Next Page Table of Contents Cognitive Load Theory and Its Impact on Diagnostic Accuracy Introduction to Diagnostic Errors Fundamental Concepts for Understanding Cognitive Load Interplay …
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www.ahrq.gov/hai/cusp/toolkit/learn-defects.htmlDecember 01, 2012 - Learn from Defects Tool CUSP Toolkit Health care organizations can increase the extent to which they learn from defects. Problem statement: Health care organizations can increase the extent to which they learn from defects. We define this learning as reducing the probability that a future patient will be h…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Pronovost_95.pdfJune 12, 2008 - Improving the Value of Patient Safety Reporting Systems Improving the Value of Patient Safety Reporting Systems Peter J. Pronovost, MD, PhD; Laura L. Morlock, PhD; J. Bryan Sexton, PhD; Marlene R. Miller, MD, MSc; Christine G. Holzmueller, BLA; David A. Thompson, DNSc, MS; Lisa H. Lubomski, PhD; Albert W. Wu, M…
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Snac-Final-Report-Mar2023 (pdf file)
www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/snac-final-report-mar2023.pdfJanuary 01, 2025 - Expanding harms defined to include physical, emotional, and financial. -
www.ahrq.gov/patient-safety/news-events/summit-research-2020/questions.htmlMarch 01, 2021 - What are the most compelling options for reframing the costs, harms, and other outcomes associated with
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NAA National Webinar, February 2025: Establishing Psychological Safety for Healthcare Workers (pdf file)
www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/psychological-safety-slides.pdfMarch 18, 2025 - NAA National Webinar, February 2025: Establishing Psychological Safety for Healthcare Workers Creating and Maintaining a Culture of Safety Series (Session 1) Establishing Psychological Safety for Healthcare Workers NATIONAL WEBINAR SERIES February 18, 2025 Housekeeping Instructions • This webinar will be record… -
114-Mrsa-Prevention-Learning-From-Defects (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/114-mrsa-prevention-learning-from-defects.docxOctober 01, 2024 - AHRQ Safety Program for MRSA Prevention Learning From Defects Tool ICU & Non-ICU Problem statement: Healthcare organizations can increase the extent to which they learn from defects. We define this learning as reducing the probability that future patients will be harmed. What is a defect? A defect is any clinical or o… -
www.ahrq.gov/patient-safety/reports/safer-together.htmlJanuary 01, 2025 - Safer Together: A National Action Plan to Advance Patient Safety Safer Together: A National Action Plan to Advance Patient Safety illuminates the collective insights of the 27 member organizations of the National Steering Committee for Patient Safety (NSC), convened in 2018 by the Institute for Healthcare Impr…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/science-of-safety-facguide.docxJanuary 01, 2017 - Look at each of these system factors and consider how each can carry a defect that leads to patient harms
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