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Showing results for "harms".
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects.pptxDecember 01, 2017 - Patient harms often have defect(s) at each of these layers. 17 LFD Tool Contributing Factors Learning
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Chapter-3 - Sepsis Recognition (pdf file)
www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/sepsis-1.pdfMarch 01, 2020 - Practice Study Design; Sample Size; Patient Population Setting Outcomes: Benefits Outcomes: Harms … Practice Study Design; Sample Size; Patient Population Setting Outcomes: Benefits Outcomes: Harms … Practice Study Design; Sample Size; Patient Population Setting Outcomes: Benefits Outcomes: Harms … Practice Study Design; Sample Size; Patient Population Setting Outcomes: Benefits Outcomes: Harms … Minimal data were reported on potential harms due to false-positive alerts. -
www.ahrq.gov/hai/pfp/interimhac2013-ref.htmlDecember 01, 2014 - Efforts To Improve Patient Safety Result in 1.3 Million Fewer Patient Harms References Previous … Page Table of Contents Efforts To Improve Patient Safety Result in 1.3 Million Fewer Patient Harms
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www.ahrq.gov/hai/pfp/interimhacrate2014.htmlJanuary 01, 2018 - An estimated 2.1 million fewer harms were experienced by patients from 2010 to 2014 than would have occurred
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/apc.htmlAugust 01, 2022 - Gap Analysis Facilitator's Guide: Appendix C Gap Analysis Structured Interview Guide To produce more consistently useful results, use structured interview questions. The facilitator should review the questions in advance to determine which questions are appropriate for each focus group session. It may help to…
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Learndefects (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/learndefects.docJune 02, 2025 - Learn From Defects Tool 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 harmed. Most often clinicians recover from mistakes by reducing risks to the patient who suffered a defect. Wh… -
www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-terminology7.htmlApril 01, 2025 - Exploration of Foundational Terminology and Paradigms for Improving Diagnosis Foundational Terminology for Diagnosis Relating to Suboptimal Processes and Outcomes Previous Page Next Page Table of Contents Exploration of Foundational Terminology and Paradigms for Improving Diagnosis Introduction …
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes4.htmlAugust 01, 2022 - Module 4: Event Reporting, Event Investigation and Analysis AHRQ Communication and Optimal Resolution Toolkit Facilitator Notes Say: Module 4 of the CANDOR Toolkit covers the Event Reporting, Event Investigation, and Analysis component of the CANDOR process. Slide 1 Say: Obje…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Schyve.pdfJune 02, 2025 - Prologue—Volume 2—Systems Thinking and Patient Safety 1 Prologue Systems Thinking and Patient Safety Paul M. Schyve Patient safety is a prominent theme in health care delivery today. This should come as no surprise, given that “first, do no harm” has been the ethical watchword throughout the history of medi…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urine-culturing.pptxApril 01, 2022 - input Attending approval Ordering Process Fever order sets Indication-based ordering UA first approach Harms … Take-Home Points Do not order a urine culture if the patient is asymptomatic Educate staff on potential harms
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www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/high-reliability-journey-slides.pptxSeptember 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 and Becoming a Learning Health System Gerard R. Cox, MD, MHA Assistant Under Secretary for Health for Quality & …
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www.ahrq.gov/hai/tools/surgery/tools/applying-cusp/perioperative-asst.htmlDecember 01, 2017 - Perioperative Staff Safety Assessment AHRQ Safety Program for Surgery Introduction Problem Statement One of the strongest determinants of safety culture is whether local and hospital leadership respond to staff patient safety concerns. Frontline providers understand patient safety risks in the…
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162-Example-Completed-Learning-Defects-Tool (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/162-example-completed-learning-defects-tool.docxOctober 01, 2024 - AHRQ Safety Program for MRSA Prevention Learning From Defects Tool - Example 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 cli… -
www.ahrq.gov/action-alliance/resources/measure-domains.htmlApril 01, 2025 - Resources by the CMS Patient Safety Structural Measure Domains The Patient Safety Structural Measure is an attestation-based measure to assess whether hospitals demonstrate having a structure and culture that prioritizes patient safety. The Patient Safety Structural Measure is informed by the National Action P…
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www.ahrq.gov/hai/tools/mvp/modules/cusp/learn-from-defects-slides.htmlFebruary 01, 2017 - Learn From Defects in Care of Mechanically Ventilated Patients: Slide Presentation AHRQ Safety Program for Mechanically Ventilated Patients Slide 1: AHRQ Safety Program for Mechanically Ventilated Patients Learn From Defects in Care of Mechanically Ventilated Patients Slide 2: Learning Objectives Af…
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Tool: Perioperative Staff Safety Assessment (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/tools/applying-cusp/perioperative_asst.docxDecember 01, 2017 - Tool: Perioperative Staff Safety Assessment AHRQ Safety Program for Surgery Perioperative Staff Safety Assessment Introduction Problem Statement One of the strongest determinants of safety culture is whether local and hospital leadership respond to staff patient safety concerns. Frontline providers understand patie… -
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/overview-cuspmvp-slides.pptxJanuary 01, 2017 - CMV_27_M3_CUSP_SSA_Premortem Overview of the Comprehensive Unit-based Safety Program for Application to Mechanically Ventilated Patients AHRQ Safety Program for Mechanically Ventilated Patients AHRQ Pub. No. 16(17)-0018-27-EF January 2017 Overview of CUSP for MVP ‹#› AHRQ Safety Program for Mechanically Ventilat…
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www.ahrq.gov/action-alliance/commitment/index.htmlOctober 01, 2024 - Commitment To Advance Patient and Workforce Safety The National Action Alliance is a community of healthcare provider organizations and federal, private, and community partners, including patients and their families, who share a commitment to forging innovative pathways toward safer healthcare for patients and …
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Boardchecklist (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/boardchecklist.docJune 02, 2025 - Checklist Items Leader Responsible Date Initiated 1. Set an organization aim of annually assessing the safety and teamwork climate. 2. Improve the safety and teamwork climate using valid measures. 3. Set expectation for unit-level culture assessment. 4. Require at least a 60 percent participation… -
Learning-From-Antibiotic-Adverse (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/learning-from-antibiotic-adverse.docxJune 01, 2021 - AHRQ Safety Program for Improving Antibiotic Use Learning From Antibiotic-Associated Adverse Events An antibiotic-associated adverse event is any event or situation that you would not want to happen again because it either caused your patient harm or had the potential to cause harm. The purpose of this tool is to provi…
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