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Showing results for "incident".

161. Using Home Visits to Understand Medication Errors in Children (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Walsh_74.pdf
     May 28, 2008 - Field, et al 200731 Chart review, computer-generated signals, and incident report review Medicare … events among older individuals using medical record review, computer generated signal review, and incident … The error reporting form provides space for a detailed description of the incident, including information … Prior research compared observation to two other commonly used methods—chart review and incident report … Direct observation was found to be more efficient and accurate than chart review and incident reports

162. Surveys on Patient Safety Culture (SOPS) Ambulatory Surgery Center Survey: 2023 User Database Report Part II (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/2023-ASC-Database-Report-II.pdf
     January 01, 2023 - 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

163. Final Progress Report: Improving Transplant Med Safety through a Pharmacist-Led, mHealth-Based Program (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/taber-report.pdf
     January 01, 2024 - intervention experienced a significant reduction in medication errors (61% reduction in risk rate; incident … interval, 0.28 to 0.55; P, 0.001) and a significantly lower risk of grade 3 or higher adverse events (incident … The intervention arm also demonstrated significantly lower rates of hospitalizations (incident risk … control arm, leading to a 61% reduction in the risk rate of medication errors over the 12-month study (incident

164. Diagnostic Safety Grants Awarded in FY 2019 | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/research/grants-2019.html
     March 01, 2024 - Diagnostic Safety Grants Awarded in FY 2019 Congress authorized $2 million in fiscal year 2019 for AHRQ to initiate a research agenda to understand and solve the problem of diagnostic errors. In 2019, AHRQ awarded the four grants below that will more precisely define the scope of diagnostic errors. Utility o…

165. 5. How do we measure our pressure ulcer rates and practices? | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/put5.html
     October 01, 2014 - Preventing Pressure Ulcers in Hospitals 5. How do we measure our pressure ulcer rates and practices? Previous Page Next Page Table of Contents Preventing Pressure Ulcers in Hospitals Overview Key Subject Area Index 1. Are we ready for this change? 2. How will we manage change? 3. What are …

166. 5. How do we measure our pressure ulcer rates and practices? | Agency for Healthcare Research and Quality
     www.ahrq.gov/es/patient-safety/settings/hospital/resource/pressureulcer/tool/put5.html
     October 01, 2014 - Preventing Pressure Ulcers in Hospitals 5. How do we measure our pressure ulcer rates and practices? Previous Page Next Page Table of Contents Preventing Pressure Ulcers in Hospitals Overview Key Subject Area Index 1. Are we ready for this change? 2. How will we manage change? 3. What are …

167. 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/hospital-version-2-resource-list.pdf
     December 01, 2024 - The Joint Commission proposes actions for all organizations to take, including developing incident reporting … 13 This AHRQ primer provides background information on voluntary patient safety event reporting (incident … The Incident Decision Tree: Guidelines for Action Following Patient Safety Incidents https://www.ahrq.gov … The Incident Decision Tree supports the aim of creating an https://staff.ihi.org/resources/Pages/Changes … Testing Process: A Step-by-Step Guide for Rapid-Cycle Patient Safety and Quality Improvement The Incident

168. Pediatric Diagnostic Safety Research and Initiatives Across the Care Continuum | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-pediatric-safety-3.html
     August 01, 2023 - This method allowed researchers to aggregate similar MDOs that were not identified through traditional incident … characterize MDOs, including clinician surveys, 101 morbidity and mortality conference reviews, 102,103 incident

169. Final Progress Report: Enhancing the Safety of Warfarin in the Nursing Home (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/gurwitz-report.pdf
     January 01, 2024 - events were lower in intervention homes, although this result was not statistically significant; the incident … For each trigger identified, the abstractors completed an abstraction form describing the incident and … When the two reviewers disagreed on the classification of an incident, its preventability, or its severity … The adjusted incident rate ratio (IRR) for any preventable warfarin-related adverse event was 0.87 ( … events were lower in intervention homes, although this result was not statistically significant: the incident

170. Suicide Risk Response: Enhancing Patient Safety Through Development of Effective Institutional Policies (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Bonner.pdf
     January 01, 2004 - spontaneous mention of suicide versus direct suicide threat); how to evaluate the severity of the incident … defined chain of responsibility 5 4.75 DOCUMENTATION A report of contact is used to document incident … is made by a clinician 4 4 A notification system is created to inform higher level personnel of incident … 4.11 3.875 In-person assistance by a mental health specialist 3.44 3 Incident reports/progress

171. Chronic Kidney Disease | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/nhqrdr/chartbooks/effectivetreatment/kidney.html
     June 01, 2018 - The cohorts include incident hemodialysis patients. … The cohorts include incident hemodialysis patients.

172. Chesapeake Regional Healthcare’s Success in Preventing Falls in Hospitals | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/about/chesapeake-regional-healthcare.html
     February 01, 2024 - The incident reporting system captured fall event documentation and was reviewed daily by Risk Management

173. Final Progress Report: Medication Error Reduction, Technologies and Human Factors (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/carayon-report.pdf
     January 01, 2024 - maintained a log of pump-related incidents that may or may not have been reported through this formal incident … the coordinator were summarized according to categories of the possible or probable source of the incident … Usability testing Schroeder et al. (2006) write of a free-flow incident attributable to the pump. … Subsequent to the incident, usability analyses were conducted that focused on a technology upgrade aimed … at ensuring a safe redesign that specifically addressed the free-flow incident.

174. Final Progress Report: Implementing Reduced Work Hours for All House Staff To Improve Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/landrigan2-report.pdf
     January 01, 2024 - a needlestick injury, of making a reported medical error, and of having an on-the-job fall- asleep incident … error or event was pursued by the chart reviewers, who collected additional information. 3) Hospital incident … reports: BWH currently has a computerized incident reporting system in place. … followed up and reviewed all data collected by observers, reported by staff, or identified through the incident … Data collected for each incident included a description of the event and patient, classification of

175. Mercy Health Uses AHRQ's Patient Safety Culture Survey and TeamSTEPPS® to Enhance Care | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/201411.html
     August 01, 2014 - The program demonstrated a 49 percent annual reduction in acute care patient handling incident reports

176. Grants to Enable Diagnostic Excellence | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/diagnostic-error-grants/index.html
     January 01, 2021 - Grants to Enable Diagnostic Excellence Congress authorized $2 million in fiscal year 2019 for AHRQ to initiate a research agenda to understand and solve the problem of diagnostic errors. In 2019, AHRQ awarded the four grants below that will more precisely define the scope of diagnostic errors. Utility of Pre…

177. Resource List - AHRQ Medical Office Survey (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/medoffice-resourcelist.pdf
     April 01, 2023 - The Joint Commission proposes actions for all organizations, including developing incident reporting … Incident Decision Tree https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety … resources/advances-in-patient-safety/vol4/Meadows.pdf The National Patient Safety Agency has developed the Incident … The Incident Decision Tree supports the aim of creating an open culture, where employees feel able to … Incident Decision Tree 4. Just Culture 5.

178. PS Grantee | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/index.html?page=14
     January 01, 2024 - Measure Development, Measure Implementation, Risk Assessment Publication Date: August 2009 Incident

179. Final Progress Report: Surveillance for Adverse Drug Events in Ambulatory Pediatrics (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/bailey-kilbridge-report.pdf
     January 01, 2024 - Adverse sedation events in pediatrics: a critical incident analysis of contributing factors. … The incident reporting system does not detect adverse drug events: a problem for quality improvement.

180. Development of the AHRQ Ambulatory Surgery Center Survey on Patient Safety Culture: Slide Presentation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/ascwebinar/smith2slides.pdf
     June 02, 2025 - When something happens that could harm the patient, but does not, how often is it documented in an incident