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Total Results: 2,353 records

Showing results for "incident".

181. Final Progress Report: Factors That Enhance Diagnostic Imaging Safety in the Ambulatory Setting (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/lacson-report.pdf
     January 01, 2025 - Final Progress Report: Factors That Enhance Diagnostic Imaging Safety in the Ambulatory Setting Project Title: Factors that Enhance Diagnostic Imaging Safety in the Ambulatory Setting Principal Investigator: Ronilda Lacson, MD, PHD Team Members: Ramin Khorasani, MD, MPH Ivan Ip, MD, MPH Sonali Desai, MD Allen Ka…

182. TeamSTEPPS Limited English Proficiency Module: Learning Outcomes Assessment (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/handouts/leputcomesasst.pdf
     July 25, 2012 - Report the incident to his supervisor d. Follow Mr.

183. Fallpxtool4B (doc file)
     www.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.

184. Fallpxtool2D (doc file)
     www.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.

185. 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

186. 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

187. 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.

188. Data Submission Dashboard (xls file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/Data_Submission_Dashboard_Data_2020.xlsx
     January 01, 2020 - 1,758,235 DS_4 DS_4: Percentage of Total Reports by Report Type Report Type Percentage Frequency Total Incident

189. 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.

190. Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/studies/index.html?page=165
     January 01, 2024 - , Goyal P , Howard G The association of hypertension, hypertension duration, and control with incident … study, the investigators examined associations of hypertension, hypertension duration, and control with incident … for Geographic And Racial Differences in Stroke study participants (n = 25 770) who were followed for incident … The association of hypertension, hypertension duration, and control with incident heart failure in black

191. 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).

192. 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

193. 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

194. 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

195. 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

196. 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

197. 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

198. 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

199. Final Progress Report: Clinical Prediction of Hepatotoxicity & Comparative Hepatic Safety of Medications (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/lo-report.pdf
     January 01, 2024 - specificity (0.92) and negative predictive value (0.99) but low sensitivity (0.68) and PPV (0.02) for incident … indicating that decreasing platelet count and increasing total bilirubin were strong predictors of incident … of Hy’s Law biochemical criteria, determined at recognition of drug-induced hepatitis, to predict incident … practice, clinicians would be unlikely to embrace a prognostic score that leads to a high rate of missed incident … Incident liver aminotransferases >200 U/L occurred in 2% of the 10,083 HIV-infected patients in the

200. 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