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Showing results for "incident".

81. Underwood Surgery Center: Slide Presentation (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/ascwebinar/tinsleyslides.pdf
    September 01, 2015 - When something happens that could harm the patient, but does not, how often is it documented in an incident

82. Improving Patient Safety in Hospitals: A Resource List for Users of the AHRQ Hospital Survey on Patient Safety Culture (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospitalresourcelist.pdf
    January 01, 2019 - The Joint Commission proposes actions for all organizations to take, including developing incident reporting … Patient Safety Primer: Voluntary Patient Safety Event Reporting (Incident Reporting) https://psnet.ahrq.gov … /13 This AHRQ primer provides background information on voluntary patient safety event reporting (incident … Incident Decision Tree https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety … The Incident Decision Tree supports the aim of creating an open culture, where employees feel able to

83. 5. How do we measure our pressure ulcer rates and practices? | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/put5.html
    October 01, 2014 - Skip to main content An official website of the Department of Health and Human Services Careers Contact Us Español FAQs Search all AHRQ sites Search small Search Menu …

84. Fallpxtool2D (doc file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallpxtoolkit/fallpxtool2d.docx
    January 28, 2013 - Accurate completion of fall incident report form by all staff? 2.

85. Fallpxtool4B (doc file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallpxtoolkit/fallpxtool4b.docx
    January 29, 2013 - Files incident report for new falls and carries out postfall assessment.

86. Identify Defects Through Sensemaking, Facilitator Notes | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/hai/cusp/modules/identify/notes.html
    December 01, 2012 - Determine the number of barriers or critical control points that were breached before the incident was … involved in the occurrence, and Document (a) the actions taken to reduce the unfavorable outcome of the incident … and (b) the recovery actions staff took following the discovery of the incident. … Staff members are responsible for investigating the causes of an incident or near-miss event, generally … When the Eindhoven Model of analysis is completed, there should be three to seven root causes for each incident

87. Appendix C: The Health Care Safety Hotline: Operations Manual (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/hotline/healthcare-safety-hotline-appendixc.pdf
    July 01, 2015 - (This step occurs only if the event is classified as an incident; near misses and unsafe conditions, … about the same incident that was submitted to the hotline. … , preventability, contributing factors, and incident type. … harm (harm incident). … harm (harm incident).

88. Standardized Simulated Events for Provocative Testing of Medical Care System Rescue Capabilities (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Blike.pdf
    January 01, 2003 - Cote et al.11 published a critical incident review of 90 pediatric sedation- related critical incidents … The critical incident analysis determined that the overwhelming majority of these deaths were avoidable … Critical event selection and refinement Based on the critical incident review of pediatric sedation-related … Adverse sedation events in pediatrics: a critical incident analysis of contributing factors [comment … Blike GT, Unpublished data regarding quality assurance incident review in the Department of Anesthesia

89. Diagnostic Safety Grants Awarded in FY 2019 | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/research/grants-2019.html
    March 01, 2024 - Skip to main content An official website of the Department of Health and Human Services Careers Contact Us Español FAQs Search all AHRQ sites Search small Search Menu …

90. References (doc file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/subglottic-litreview.docx
    January 01, 2017 - References Summary Continuous or frequent intermittent suctioning of subglottic secretions, via an endotracheal tube (ETT) specially designed with a dorsal lumen to accommodate this, is associated with up to a 50 percent decreased incidence of aspiration and ventilator-associated pneumonia (VAP). Guidelines support …

91. Implementation of a Data-based Medical Event Reporting System in the U.S. Department of Defense (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Davis.pdf
    February 12, 2004 - facilities (MTFs)—144 facilities, including 71 clinics and 73 hospitals—have been instructed to report incident … Since no comparable national medical error incident reporting system was in place, a new system needed … Each safety event incident report is reviewed by the PSO/M, who decides on the appropriate category … All incident information not included in the spreadsheet stays at the MTF. … While low volume reporting may be due, at least in part, to reliance on an incident-report based system

92. Making Information Technology a Team Player in Safety: The Case of Infusion Devices (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Nemeth.pdf
    January 01, 2002 - Food and Drug Administration (FDA) incident reports and field studies. … How do existing incident reports help to describe adverse events in terms of infusion device programming … Reports in the MAUDE medical device incident-tracking system indicate that practitioner difficulties … There is no suggestion that a single design flaw produced the user difficulties that incident reporting … Features of infusion device related incidents revealed by systematic analysis of an incident reporting

93. Structure and Features of a Care Enhancement Model Implementing the Patient Safety and Quality Improvement Act (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Riley_59.pdf
    April 06, 2008 - Furthermore, the Act provides for a national Network of Patient Safety Databases (NPSD) of voluntary incident … sharp end,” and hence, is responsible for in-depth event investigation to assess associated event or incident … is currently done and must be acted upon at the level where system weaknesses are found.14 The incident … In this incident causation model, near misses are precursors to possible adverse events. … only be developed by extensive accountability at the provider organization that acts on near miss and incident

94. Patient Safety Learning Pilot: Narratives from the Frontlines (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Kellie_30.pdf
    April 21, 2008 - C “A diverse incident reporting structure has been developed in an effort to optimize the reporting … The main method used to report incidents consists of a paper incident report, which is completed by the … The online entry is response-defined: responses are requested based on the type of incident initially … selected in a table of incident types. … Control charts are utilized to monitor trends and processes in using the incident reporting system to

95. Grants to Enable Diagnostic Excellence | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/diagnostic-error-grants/index.html
    January 01, 2021 - Skip to main content An official website of the Department of Health and Human Services Careers Contact Us Español FAQs Search all AHRQ sites Search small Search Menu …

96. Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/research/findings/studies/index.html?page=1
    January 01, 2024 - during early adulthood with hypertension and hyperglycemia outcomes measured in mid-adulthood, including incident … Incarceration was associated with incident hypertension (ARR 2.5) among Asian subgroups. … This study’s objective was to understand the insights conveyed in hospital incident reports about how … The authors randomly selected 100 medication safety incident reports from an academic medical center … Results showed that among 35 near misses/errors, incident reports described contributing factors (mean

97. Sustainability-Tool (doc file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/training-tools/sustainability-tool.docx
    May 01, 2017 - Observer role Technical assistance role Data collection role (e.g., review charts or incident

98. Fallpxtool6A (doc file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallpxtoolkit/fallpxtool6a.docx
    January 01, 2007 - Observer role Technical assistance role Data collection role (e.g., review charts or incident

99. Module 5: How To Measure Pressure Injury Rates and Prevention Practices (doc file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module5/module5_pu_measurement.docx
    January 01, 2016 - participants: · Module 5 PowerPoint slide presentation handout, 3 slides to a page · The hospital’s Incident

100. Final Progress Report: VTE Safety Toolkit: A Systems Approach to Patient Safety (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/2024-02/zierler-report.pdf
     January 01, 2024 - Final Progress Report: VTE Safety Toolkit: A Systems Approach to Patient Safety Title: VTE Safety Toolkit: A Systems Approach to Patient Safety Principal Investigator: Brenda K. Zierler, PhD1 Team Members: Ann Wittkowsky, PharmD2 Robb Glenny, MD3 Seth Wolpin, PhD1 Jung-Ah Lee, MN1 Gene Peterson, MD, PhD3 Fre…