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Total Results: 1,527 records

Showing results for "incident".

121. Implementation of a Data-based Medical Event Reporting System in the U.S. Department of Defense (pdf file)
     www.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

122. 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

123. 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

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. Using Rapid-Cycle Research to Reach Goals: Awareness, Assessment, Adaptation, Acceleration (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/final-rapid-cycle-research-guidance.pdf
     June 01, 2015 - Ranking method 3.2.3 Critical Incident Technique The critical incident technique (CIT) was developed … Analysing potential harm in Australian general practice: an incident-monitoring study. … Analysing potential harm in Australian general practice: an incident-monitoring study. … The critical incident technique. Psychol Bull 1954 Jul;51(4):327-58. PMID: 13177800. … This article discusses 18 individual interviews using a Critical Incident Technique.

129. 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

130. 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

131. 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

132. 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.

133. 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

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. 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.

136. 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

137. 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.

138. 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.

139. 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.

140. Opportunities and Challenges Ahead | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-dx-stewardship8.html
     August 01, 2024 - For example, van Moll and colleagues described an analysis of voluntary incident reports at an academic