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Total Results: 1,450 records

Showing results for "incident".

121. Making Information Technology a Team Player in Safety: The Case of Infusion Devices (pdf file)
     www.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

122. 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

123. Identify Defects Through Sensemaking, Facilitator Notes | Agency for Healthcare Research and Quality
     www.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

124. Sustainability Tool - Sustainability Module | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/training-tools/tool.html
     June 01, 2017 -   Technical assistance role    Data collection role (e.g., review charts or incident

125. Appendix C. Sample Search Strategies | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/engage/appc.html
     March 01, 2017 - human engineering [ti] OR Communication OR judgment [mh] OR Problem solving [mh] OR disclosure [ti] OR (incident

126. 2025 AHRQ Surveys on Patient Safety Culture® (SOPS®) Nursing Home Survey Version 2.0 Pilot Test Results: Appendix—Results by Respondent Characteristics (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/2025-nursing-home-20-pilot-test-results-appendix.pdf
     January 01, 2025 - Mistakes (e.g., feel safe reporting mistakes, are treated fairly, and are supported when involved in an incident … A11) 84% 69% 55% 66% 58% 78% 81% Staff are supported when they are involved in a resident safety incident … (Item A11) 63% 63% 64% 73% Staff are supported when they are involved in a resident safety incident … (Item A11) 71% 72% 53% Staff are supported when they are involved in a resident safety incident. … (Item A11) 72% 69% 63% 70% 70% Staff are supported when they are involved in a resident safety incident

127. Appendix D: Alternate Care Facility Questionnaire—Summary of Results | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/shuttered/acfselection/appendixd.html
     July 01, 2018 - Yes—County Health Dept was large part of the governance of the [site] and therefore they were incident … Collective decision between the Incident Commander, the Emergency Manager, the Medical Director and the … Since in almost every major incident there are public information issues we anticipate there will be … Local EMS was coordinated through the incident command Through the Incident Commander and appropriate … Respect, adapt Need strong incident command to manage multiple levels of outside input. .

128. Chapter 2. Fall Response | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man2.html
     December 01, 2017 - Investigate Fall Circumstances If fall circumstances are not investigated at the time of the incident … and Staff Response A written full description of all external fall circumstances at the time of the incident

129. Appendix 3-A. Suggested Slides for Module 3 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/gdmodap3a.html
     October 01, 2014 - You must go beyond an incident report to develop a revised care plan.

130. Sustainability-Tool (doc file)
     www.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

131. Newman Memorial Hospital Implements AHRQ's Patient Safety Culture Survey | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/cquips1301.html
     November 01, 2012 - implementation of AHRQ's "Hospital Survey on Patient Safety Culture" at Newman Memorial Hospital, only one incident

132. Standardized Simulated Events for Provocative Testing of Medical Care System Rescue Capabilities (pdf file)
     www.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

133. Developing a Taxonomy of Anesthetists’ Nontechnical Skills (ANTS) (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Patey.pdf
     January 01, 2004 - Critical incident studies in anesthesia have found that around 80 percent of reported incidents involve … operating room, recoding a sample of the interview transcripts, and reviewing 200 anesthesia critical-incident … System, and difficulty to use if the consultant is heavily involved in the case or if there is an incident … The Australian incident monitoring study. … An analysis of 2,000 incident reports. Anaesth & Int Care 1993; 21:506–19. 4.

134. Mapping a Large Patient Safety Database to the 2005 Patient Safety Event Taxonomy (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Clarke_8.pdf
     January 25, 2008 - The main descriptive element is what others might call the “incident type,” but which we call the … “event type” – given the very specific definition for “incident” in the MCARE law, as noted above. … We feel that a field describing the provider-reported descriptive event type (or incident type as understood … Alternatively, the event type (or incident type as understood by others) used by PA-PSRS is a description … We believe a descriptive event type, or incident type, based on process of care or clinical outcome

135. Grantees Focusing on African Americans | Agency for Healthcare Research and Quality
     www.ahrq.gov/priority-populations/observances/bhm/grantees.html
     February 01, 2021 - The project will examine temporal trends in incident mastectomy and breast-conserving surgery and will

136. Module 1: Communication and Optimal Resolution (CANDOR) Toolkit Module 1: An Overview of the CANDOR Process
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/module1-overview.pptx
     June 02, 2025 - to none Extensive and ongoing Communication with patient, family Deny/defend Transparent, ongoing Incident … In the past, incident reporting by clinicians has been delayed or often absent.

137. AHRQ's Patient Safety Culture Survey Yields Meaningful Results at Palo Alto Medical Foundation | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/cquips0603.html
     October 01, 2014 - The survey revealed that 76 percent of employees have never completed an incident report.

138. 152-Cusp-Tip-Sheet-Engaging-Physicians (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/152-cusp-tip-sheet-engaging-physicians.docx
     October 01, 2024 - Smith to discuss this incident and see how we can address Dr.

139. Windows of Opportunity | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-sustainability-centers-of-excellence6.html
     April 01, 2025 - This incident galvanized the institution’s executive leadership to take decisive action. 16   Exhibit

140. Surveys on Patient Safety Culture (SOPS) Ambulatory Surgery Center Survey: 2021 User Database Report Part II (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/Part-II-SOPS-ASC-DatabaseReport.pdf
     December 01, 2021 - respondents who indicated that near-miss incidents were “Always” or “Most of the time” documented in an incident … When something happens that could harm the patient, but does not, how often is it documented in an incident … When something happens that could harm the patient, but does not, how often is it documented in an incident … When something happens that could harm the patient, but does not, how often is it documented in an incident … When something happens that could harm the patient, but does not, how often is it documented in an incident