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Showing results for "incident".
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Making Healthcare Safer Practices: 11. Patient Identification Errors in the Operating Room (pdf file)
www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/patient-id-errors-1.pdfMarch 01, 2020 - Making Healthcare Safer Practices: 11. Patient Identification Errors in the Operating Room Patient Identification Errors in the Operating Room 11-1 11. Patient Identification Errors in the Operating Room Authors: Cori Sheedy, Ph.D., and Sonja Richard, M.P.H. Introduction In the first Making Health Care Safer … -
May 2025: National Action Alliance for Patient and Workforce Safety Webinar Chat Transcript (pdf file)
www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/implementing-cms-measure-chat-transcript.pdfMay 01, 2025 - We added the after-action review tool as a debriefing tool as part of our incident management system -
www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/case.htmlDecember 01, 2017 - AHRQ's Safety Program for Nursing Homes Case Studies These case studies follow three nursing home facilities that implemented the On-Time Pressure Ulcer Prevention Program. Select for more AHRQ Impact Case Studies . Contents New York Nursing Facility Sees 56 Percent Drop in Pressure Ulcers with AHRQ-Fu…
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www.ahrq.gov/sites/default/files/publications/files/haify11.pdfJanuary 01, 2011 - AHRQ Projects to Prevent Healthcare-Associated Infections, Fiscal Year 2011 Introduction Healthcare-associated infections (HAIs) are infections that people acquire while they are receiving treatment for another condition in a health care setting. They are costly, deadly, and largely preventable. A core part of the Ag…
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www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu6.htmlOctober 01, 2014 - Preventing Pressure Ulcers in Hospitals 6. How do we sustain the redesigned prevention 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 the…
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www.ahrq.gov/es/patient-safety/settings/hospital/resource/pressureulcer/tool/pu6.htmlOctober 01, 2014 - Preventing Pressure Ulcers in Hospitals 6. How do we sustain the redesigned prevention 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 the…
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Surveys on Patient Safety Culture (SOPS) Nursing Home Survey: 2023 User Database Report Part I (pdf file)
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/SOPS-Nursing-Home-DB-Part-I-2023.pdfJanuary 01, 2023 - Surveys on Patient Safety Culture (SOPS) Nursing Home Survey: 2023 User Database Report Part I SURVEYS ON PATIENT SAFETY CULTURE Nursing Home Survey: 2023 User Database Report Surveys on Patient Safety Culture™ PATIENT SAFETY [This page intentionally left blank] Surveys on Patient Safety CultureTM (SOPS®)… -
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-nephro.pdfJune 02, 2025 - NICU Family Information Packet, Appendix B, Nephrocalcinosis Nephrocalcinosis Characteristics ■ Renal lithiasis in which calcium deposits form in the renal parenchyma and result in reduced kidney function and hematuria. ■ Seen with renal ultrasound, or occasionally on plain radiographs of the kidneys. ■ Resul…
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Using Probabilistic Risk Assessment to Model Medication System Failures in Long-term Care Facilities (pdf file)
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Comden.pdfJanuary 01, 2003 - the medication delivery systems in LTC facilities is fragmented, largely drawn from retrospective incident … are designed to evolve as fresh data from new studies, patient safety reporting systems, or facility incident … the time and/or resources to thoroughly understand the elements and risk factors that led up to the incident -
www.ahrq.gov/sites/default/files/2025-03/newman-toker-report.pdfJanuary 01, 2025 - Final Progress Report: A Multiyear Grant To Support the Diagnostic Error in Medicine (DEM) Annual Conference FINAL PROGRESS REPORT TITLE PAGE (R13HS019252, PI Newman-Toker) Title: A Multiyear Grant to Support the Diagnostic Error in Medicine (DEM) Annual Conference Principal Investigator: David E. Newman-Toker Tea…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/unc-webcast-transcript.pdfJanuary 01, 2020 - /www.ahrq.gov/sops/index.html 5 Mazur, Slide 22 Finally, we needed to organize a more formal incident … And when submitted, they were directed to our Risk Management Department and mostly representing incident … of occurrence don't get lost in that kind of one off report where the severity for that particular incident … What is the average time that it takes up frontline staff member to complete an incident report?
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/report/apv1b.htmlJune 01, 2010 - Environmental Scan of Measures for Medicaid Title XIX Home and Community-Based Services Appendix V (continued) Previous Page Next Page Table of Contents Environmental Scan of Measures for Medicaid Title XIX Home and Community-Based Services Executive Summary Introduction and Scan Methodology E…
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www.ahrq.gov/sites/default/files/2024-11/sarkar2-report.pdfJanuary 01, 2024 - which has been subject to numerous biases in previous research.23,33,34 Several studies have used incident … reporting to identify outpatient adverse events,35–37 but incident reporting is known to capture only … Analysing potential harm in Australian general practice: an incident- monitoring study.
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www.ahrq.gov/policymakers/chipra/measure_retirement/index.htmlFebruary 01, 2014 - Background Report on 2013 Retirement of Measures from the Child Core Set Next Page Table of Contents Background Report on 2013 Retirement of Measures from the Child Core Set Abstract Background Methods Results Conclusions References Appendix A. Appendix B. Appendix C. Appendix D…
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www.ahrq.gov/hai/tools/mvp/modules/vae/tool.htmlJanuary 01, 2017 - Ventilator-Associated Event Data Collection Tool AHRQ Safety Program for Mechanically Ventilated Patients Date __________ Month __________ Hospital __________ Unit __________ Use this tool to track your progress in reducing ventilator-associated event (VAE) rates by using this inform…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/vae/monitoring-vae-slides.pptxJanuary 01, 2017 - Monitoring Ventilator-Associated Events Module 2 Monitoring Ventilator-Associated Events AHRQ Safety Program for Mechanically Ventilated Patients AHRQ Pub. No. 16(17)-0018-26-EF January 2017 Monitoring VAEs ‹#› AHRQ Safety Program for Mechanically Ventilated Patients 1 Learning Objectives After this sessio…
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www.ahrq.gov/sites/default/files/2024-01/bundy-report.pdfJanuary 01, 2024 - Final Progress Report: Pediatric Medication Safety: Analyses from the MEDMARX Medication Error Reporting System Pediatric Medication Safety: Analyses from the MEDMARX Medication Error Reporting System Principal Investigator: David G. Bundy, MD, MPH Team Members: Marlene R. Miller, MD, MSc Michael L. Rinke, M…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Weinberg.pdfMarch 01, 2004 - subsequently passed a mandatory reporting statute that requires institutions to summarize and post “adverse incident … New York protects incident reports from “public disclosure”; however “the [reporting] system is nonpunitive … NASHP notes that the most frequent use of data from incident or error reports is aggregating data to … States in our analysis require health care institutions to adopt patient safety plans for reviewing incident
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Navigating-Hierarchy-Transcript (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/navigating-hierarchy-transcript.docDecember 10, 2013 - You know, you could spend an hour debriefing that one incident but it was never discussed and we rarely … discuss when we have that kind of an incident occur. … So make sure that when you do see an incident, that something like that happens, that you either see … next steps that a nurse or (indiscernible 41:56) health care worker can utilize when they’re in an incident -
www.ahrq.gov/hai/cauti-tools/archived-webinars/navigating-hierarchy-transcript.htmlDecember 01, 2017 - You know, you could spend an hour debriefing that one incident but it was never discussed and we rarely … discuss when we have that kind of an incident occur. … So make sure that when you do see an incident, that something like that happens, that you either see … next steps that a nurse or (indiscernible 41:56) health care worker can utilize when they're in an incident
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