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Showing results for "incident".

101. Final Progress Report: Improving Medication Safety Across Clinical Settings (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/bates-report.pdf
     January 01, 2024 - Incident and error-reporting systems are not widely used, especially by physicians, due to cultural … Context: Review of incident reports entered into the new web-based incident reporting system at Brigham … Limitations: Review of incident reporting data was limited to one institution. … The leading incident categories were labs (30%), followed by medication issues (17%), falls (11%), and … Submission of incident reports by physicians remained small but did increase with the Final Report:

102. Facilities | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/shuttered/toolkitchecklist/surgetkit2.html
     July 01, 2018 - Orientation, Training, and Support Provide training on Incident Command System (or another organization … Identify Sources for Staffing Notify Incident Command (or Management Team Leader) of staffing needs … Updating Sources for Staffing (Based on Patient Population at the End of Opening Day) Update Incident … Daily Update Sources for Staffing Update Incident Command (or Management Team Leader) of any changes … Action Checklist Informing All Staffing Sources and Vendors of Closure Update Incident Command

103. A Visual Computer Interface Concept for Making Error Reporting Useful at the Point of Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Singh_69.pdf
     April 04, 2008 - By reducing an incident to a series of codes, the flavor of the event is lost. … For example, perceptions of contributing factors will likely vary among reporters for the same incident … Incident reporting systems in medicine and experience with the Aviation Safety Reporting System. … Integrating incident reporting into an electronic patient record system. … Rates and types of events reported to establish incident reporting systems in two U.S. hospitals.

104. Hospital Evacuation Decision Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/shuttered/hospevac4.html
     July 01, 2018 - evacuation decision for a lengthy period of time in the aftermath of the Three Mile Island (Pennsylvania) incident … local emergency management agencies for the first 3 days after the Three Mile Island (Pennsylvania) incident

105. Mixed Methods Analysis of Medical Error Event Reports: A Report from the ASIPS Collaborative (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Harris.pdf
     June 30, 2004 - inform the development of interventions to improve patient safety, but only if the data contained in incident … One component of these efforts is the use of incident reporting systems that collect information about … As McGreevy explains, “[T]he large numbers of incident reports and the many details they contain can … Adopting or adapting the protocol we describe in this paper to incident reporting systems in ambulatory … A practical guide to interpretation of large collections of incident narratives using the QUORUM method

106. The National Action Alliance to Advance Patient Safety Summer Webinar Series: CDC Presentation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/addressing-workforce-safety-062723.pdf
     July 25, 2023 - job duties the patient (or those with them such as family or associates) are involved in a violent incident … or had a personal relationship with a worker within the business or establishment where the violent incident … Procedures for identifying risk factors  Procedures to correct workplace violence hazards  Violent Incident … engineering and work practice controls to correct workplace violence hazards, input into a violent incident … Scale your program’s engagement: daily safety huddles, weekly incident reviews, monthly WPV prevention

107. Involving Patients and Families in Safety: Slide Presentation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/involving-patients-families-in-safety-slides.pdf
     July 25, 2023 - Stakeholders sharing and reporting to: • National and state regulatory bodies • National patient safety incident … Events A longstanding Minnesota project in partnership with MDH and with MN Hospital Association Incident … Stakeholders sharing and reporting to: National and state regulatory bodies National patient safety incident

108. TeamSTEPPS for Diagnosis Improvement: Knowledge Assessment (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/dxsafety-knowledge-assessment.pdf
     February 01, 2022 - Dismiss the incident because the physician is in charge. b. … Arrange a meeting with their supervisor to report the incident. e.

109. SOPS Bibliography | Agency for Healthcare Research and Quality
     www.ahrq.gov/sops/bibliography/index.html?page=6
     January 01, 2025 - Psychological impact and recovery after involvement in a patient safety incident: A repeated measures … Measurable improvement in patient safety culture: A departmental experience with incident learning.

110. Healthcare Safety Competencies Affinity Group | Agency for Healthcare Research and Quality
     www.ahrq.gov/action-alliance/competencies-affinity-group/index.html
     May 01, 2025 - Worker Safety Relationship and Continuum Patient/Family Engagement Patient-Centered Care  Post Harm Incident—Care

111. Final Progress Report: Identifying and Reducing Errors in Perioperative Anesthesia Medication Delivery (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/catchpole2-report.pdf
     January 01, 2025 - thinking • Highly variable definitions of error • Lack of clarity over what and when to report as an incident … CONTEXT: Incident Reporting It is well acknowledged that incident reporting under-represents the frequency … responded to the survey question, only 33% formally reported the event(s) through the institution incident … Initiated by a local clinical incident, a set of icons was designed for use on intravenous (IV) bags … Understanding the limitations of incident reporting in medication errors.

112. SOPS Bibliography | Agency for Healthcare Research and Quality
     www.ahrq.gov/es/sops/bibliography/index.html?page=6
     January 01, 2025 - Psychological impact and recovery after involvement in a patient safety incident: A repeated measures … Measurable improvement in patient safety culture: A departmental experience with incident learning.

113. Final Progress Report: Communication to Prevent and Respond to Medical Injuries: WA State Collaborative (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/gallagher1-report.pdf
     January 01, 2024 - The crux of the program is that healthcare providers who injure a patient should report the incident … Second, the CRP required the partner organization that was first notified of the incident to report … the incident promptly to other involved organizations participating in the CRP (and to reach out to … • Delays in incident reporting. … In at least two cases, hard feelings arose over how one of the organizations handled an incident.

114. Final Progress Report: APPLIED STRATEGIES FOR IMPROVING PATIENT SAFETY (ASIPS) (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/pace-report.pdf
     January 01, 2024 - used a newly created voluntary error reporting system that permits us to sort and analyze reported incident … Fischer and colleagues reviewed malpractice incident reports from primary care offices.2 Though a low … For anonymous reports, users provided detailed information concerning the incident, the patient, and … the context in which the incident occurred. … Analysing potential harm in Australian general practice: an incident-monitoring study.

115. Underwood Surgery Center: Slide Presentation (pdf file)
     www.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

116. Appendix C: The Health Care Safety Hotline: Operations Manual (pdf file)
     www.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).

117. Data Submission Dashboard (xls file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/Data_Submission_Dashboard_Data_2024.xlsx
     January 01, 2024 - 2,567,292 90.5% DS_4 DS_4: Percentage of Total Reports by Report Type Report Type Percentage Frequency Incident

118. Patient Safety Learning Pilot: Narratives from the Frontlines (pdf file)
     www.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

119. Improving Patient Safety in Hospitals: A Resource List for Users of the AHRQ Hospital Survey on Patient Safety Culture (pdf file)
     www.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

120. Structure and Features of a Care Enhancement Model Implementing the Patient Safety and Quality Improvement Act (pdf file)
     www.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