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Showing results for "incidents".

1. The Incident Decision Tree: Guidelines for Action Following Patient Safety Incidents (pdf file)
   ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Meadows.pdf
   December 01, 2003 - The Incident Decision Tree: Guidelines for Action Following Patient Safety Incidents 387 The Incident … Research shows that systems failures are the root cause of the majority of safety incidents. … • Improving understanding of the causes of adverse incidents and near incidents. … It is estimated that up to half of all incidents may be preventable.1 The way in which such incidents … • The majority of incidents appear to involve protocol violation.

2. Network of Patient Safety Databases Chartbook, 2021 (pdf file)
   ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2021.pdf
   January 01, 2021 - Five EVENT TYPES can be reported as Incidents or Near misses. … The most frequent answer value reported Fall Incidents. … ) of Fall Incidents. … This figure includes Incidents where the EXTENT OF HARM was reported. … The proportion of Incidents with residual harm was highest among Incidents originating with Purchasing

3. Network of Patient Safety Databases Chartbook, 2019 (pdf file)
   ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2019.pdf
   January 01, 2019 - Five EVENT TYPES can be reported as Incidents or Near misses. … Most HIT-RELATED DEVICE Incidents did not result in any harm. … (7 / 65,013) of Fall Incidents. … This figure includes Incidents where the EXTENT OF HARM was reported. … The proportion of Incidents with residual harm was highest among Incidents originating with Purchasing

4. Chartbook on Patient Safety (pdf file)
   ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2020.pdf
   January 01, 2020 - Five EVENT TYPES can be reported as Incidents or Near misses. … This figure includes Incidents where the EXTENT OF HARM was reported. … ) of Fall Incidents. … This figure includes Incidents where the EXTENT OF HARM was reported. … The proportion of Incidents with residual harm was highest among Incidents originating with Purchasing

5. Network of Patient Safety Databases Chartbook, 2023 (pdf file)
   ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2023.pdf
   January 01, 2023 - Finally, while there is a recognized need to collect data on Venous Thromboembolism Incidents, the … Four EVENT TYPES can be reported as Incidents, Near misses, or Unsafe conditions. … Surgery or Anesthesia event types can be reported as Incidents or Near misses. … (21,967 / 95,918) and 23.8% (7,335 / 30,843) of Incidents and Near misses, respectively. … Both near misses and unsafe conditions may occur more commonly in practice than incidents.

6. Improving the Value of Patient Safety Reporting Systems (pdf file)
   ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Pronovost_95.pdf
   June 12, 2008 - A well-functioning PSRS should collect events (incidents) that could or did lead to patient harm. … In essence, incidents should be used as golden nuggets of data to address and fix a specific hazard … This was one of many cases found when the ICUSRS team reviewed incidents to evaluate underreporting … How to place incidents into taxonomies? … Understanding incidents in the aggregate requires a classification of those incidents.

7. Appendix D: Methods | Agency for Healthcare Research and Quality
   ce.effectivehealthcare.ahrq.gov/health-literacy/professional-training/lepguide/app-d.html
   September 01, 2020 - used a pilot project with interpreters to gather additional insight into the types of patient safety incidents … quality and safety events were reported to hospital quality and safety leadership immediately; otherwise, incidents … We collected information on 34 incidents between April 2009 and March 2010 (28 of which met the specific … We identified all incidents reported as Incidents since all events reached the patient.

8. Surveys on Patient Safety Culture (SOPS) Nursing Home Survey: 2023 User Database Report Infographic Summary (pdf file)
   ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/2023-SOPS-Nursing-Home-DB-Infographic.pdf
   January 01, 2023 - 64% positive response Highest Scoring Composite Measure: Feedback and Communication About Incidents … safe, tell someone if they see something that might harm a resident, and talk about ways to keep incidents

9. NPSD Dashboards | Agency for Healthcare Research and Quality
   ce.effectivehealthcare.ahrq.gov/npsd/data/dashboard/index.html
   October 01, 2023 - including description of substance event, stage event originated, and type of substance involved for incidents … , near misses, and unsafe conditions, then further examines incidents and near misses along with their … including description of substance event, stage event originated, and type of substance involved for incidents … analyses that examine their contributing factors and preventability, as well as distribution by age group (incidents

10. SOPS Nursing Home Survey: What You Need To Know - Theresa Famolaro, MPS, MS, MBA (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/04-nh_webcast-famolaro.pdf
    September 21, 2022 - Feedback & Communication About Incidents 85% 83% 54% 100% 3. … % Positive Response Overall Perceptions of Resident Safety 85% Feedback and Communication About Incidents … Safety indicated that residents are well cared for and safe 85% Feedback and Communication About Incidents … reported that staff discuss ways to keep residents safe and incidents from happening again AREAS … Positive Response Overall Perceptions of Resident Safety 91% 85% Feedback and Communication About Incidents

11. Network of Patient Safety Databases Falls Chartbook, 2023 (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-falls-chartbook-2023.pdf
    January 01, 2023 - harm) 3 FALLS The Fall event type in CFER-H V1.2 is designed to collect information on Incidents … Among Fall Incidents, the majority of falls were experienced by adults aged 18-64 years (44.3%; 47,131 … For all 243,449 reported Fall Incidents: 7,523 (3.1%) indicated injury and residual harm to the patient … For all 243,449 reported Fall Incidents: 7,523 (3.1%) indicated injury and harm to the patient and … In the following analyses, frequent combinations (patterns) of interventions for Fall Incidents with

12. Surgical Patient Experience of Care Survey Design Project (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/surgical/about/F2CGLizHoyRogerLevine.pdf
    November 20, 2008 - CG-CAHPS – Interviews conducted with 168 patients and 39 providers – Collected 2,997 critical incidents … – 294 of these incidents were either patient reports of office visits to a surgeon or were surgeon … reports about an office visit Critical Incident ResultsCritical Incident Results Surgeon Incidents … % Other Provider Incidents % Prob.

13. Nursing Home Survey on Patient Safety Culture: 2019 User Database Report Part II (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/2019-nhsops-dbreport-partii.pdf
    January 01, 2019 - Feedback and Communication About Incidents 1. … Feedback and Communication About Incidents 1. … Feedback and Communication About Incidents 1. … Feedback and Communication About Incidents 1. … Feedback and Communication About Incidents 1.

14. 2016 AHRQ Nursing Home Survey on Patient Safety Culture Part II (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/nursing-home/2016/nhsurv16-pt2.pdf
    January 01, 2016 - Feedback and Communication About Incidents 1. … Feedback and Communication About Incidents 1. … Feedback and Communication About Incidents 1. … Feedback and Communication About Incidents 1. … Feedback and Communication About Incidents 1.

15. Physician-Reported Adverse Events and Medical Errors in Obstetrics and Gynecology (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-November_45.pdf
    January 01, 2007 - Nine patients experienced two or more incidents. 3 Demographics Table 1. … based 30 50 Community health center 6 10 HMO 8 13 Resident clinic 9 15 The majority of incidents … Potential AEs accounted for the largest percentage of incidents (46 percent), a class of incidents that … Second, those who report incidents must feel their time has been well spent, so it is vital they know … with administrators, we gave formal reports to the departmental Quality Improvement Committee, where incidents

16. The National Action Alliance to Advance Patient Safety Summer Webinar Series: CDC Presentation (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/action-alliance/addressing-workforce-safety-062723.pdf
    July 25, 2023 - other means of emergency communication that limit staff’s ability to appropriately respond to violent incidents … Approximately 9% of nurses, or about 1 in 10, felt reporting incidents to management was more difficult … Going through past records of incidents is advisable, but also being mindful of workplace violence that … in 10 nurses found it more challenging to report their incident are so important – already too many incidents … Then each of 5 case studies presented by video-based scenarios based on real-life incidents are their

17. Surveys on Patient Safety Culture (SOPS) Nursing Home Survey: 2023 User Database Report Part I (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/SOPS-Nursing-Home-DB-Part-I-2023.pdf
    January 01, 2023 - Feedback and Communication About Incidents Staff discuss ways to keep residents safe, tell someone if … they see something that might harm a resident, and talk about ways to keep incidents from happening … Highlights HIGHEST Scoring Composite Measure Feedback and Communication About Incidents 83% of … (Item B4) 81% In this nursing home, we talk about ways to keep incidents from happening again. … Feedback and Communication About Incidents 83% 11.40% 43% 68% 77% 85% 90% 95% 100% 2.

18. Surveys on Patient Safety Culture (SOPS) Nursing Home Survey: 2023 User Database Report Part II (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/2023-SOPS-Nursing-Home-DB-Part-II.pdf
    January 01, 2023 - Feedback and Communication About Incidents 86% 81% 2. … Feedback and Communication About Incidents 78% 84% 2. … Feedback and Communication About Incidents 77% 83% 87% 81% 2. … Feedback and Communication About Incidents 80% 89% 2. … Feedback and Communication About Incidents 85% 78% 79% 2.

19. A Study of Adverse Occurrences and Major Functional Impairment Following Surgery (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Rojas.pdf
    March 15, 2004 - studies that have used comparison groups have focused on death as the outcome and found that adverse incidents … Not all incidents were the result of medical treatment. … Nurses were trained to identify whether incidents occurred—not whether the occurrences were due to medical … By adopting the approach of examining the presence of incidents rather than attempting to discern errors … Like other studies, we found that adverse incidents increased LOS.23–25 Zhan & Miller, 17 looking at

20. Albuquerque Police Department Uses AHRQ Resources for Crisis Intervention Team Training | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/news/newsroom/case-studies/201708.html
    May 01, 2017 - Of 2,064 crisis intervention-related incidents that occurred from January through November 2016 in the … APD records show that crisis intervention-related incidents increased nearly 60 percent from 2010 to