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Showing results for "incidents".

1. The Incident Decision Tree: Guidelines for Action Following Patient Safety Incidents (pdf file)
   www.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. Final Progress Report: Patient Safety in Hospice Care (pdf file)
   www.ahrq.gov/sites/default/files/2024-10/smucker-report.pdf
   January 01, 2024 - Interviewees often characterized such risks or incidents as being outside of their control to prevent … care, only a few interviewees recalled any incidents or harm related to errors or missed opportunities … Aim 3: Identify opportunities for preventing patient safety incidents or for detecting them early to … Patient Safety Incidents Conceptual Framework: For our study, we used the conceptual framework from … We will also explore the impact of patient safety incidents on the patients’ family caregivers.

3. Network of Patient Safety Databases Chartbook, 2021 (pdf file)
   www.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

4. Chartbook on Patient Safety (pdf file)
   www.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. Final Progress Report: Evaluate the Effects of the Massachusetts Reporting System (pdf file)
   www.ahrq.gov/sites/default/files/2024-11/ridley-report.pdf
   January 01, 2024 - Results: Aim 1: Of 760 MARS incidents, 66% met some NQF criteria. … Researchers collected data on 800 incidents. … high-injury-severity incidents conformed to the 2006 NQF standard. … Nearly all of the additional conforming incidents were a result of the inclusion incidents in which … In general, hospitals reported corrective actions for 40% of reported incidents.

6. Final Progress Report: Incident Reporting Practices in Nursing Homes (pdf file)
   www.ahrq.gov/sites/default/files/2025-02/castle-report.pdf
   January 01, 2025 - , but falls, other incidents, and pressure ulcers are not. … Clearly, these incidents represent a significant problem in nursing homes. … One start to reducing adverse incidents is to use reporting systems. … Their design allows ease of entering and analysis of adverse incidents. … , but falls, other incidents, and pressure ulcers are not.

7. Blood Dashboard Data (xls file)
   www.ahrq.gov/sites/default/files/wysiwyg/npsd/Blood_Dashboard_Data_2024.xlsx
   January 01, 2024 - ., VII, VIII, IX, AT III) * * NOTE: The 'Percentage' cells are calculated as the percentage of all incidents … NOTE: The 'No Harm Percentage' and 'Harm Percentage' cells are calculated as the percentage of all incidents … 1.5% 47 Sample testing 2.5% 45 NOTE: The 'Percentage' cells are calculated as the percentage of all incidents … NOTE: The 'No Harm Percentage' and 'Harm Percentage' cells are calculated as the percentage of all incidents … selection * * Sample handling * * NOTE: The Percentage cells are calculated as the percentage of all incidents

8. Network of Patient Safety Databases Chartbook, 2023 (pdf file)
   www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2023-rev.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.

9. Device or Medical/Surgical Supply including Health Information Technology Dashboard (xls file)
   www.ahrq.gov/sites/default/files/wysiwyg/npsd/Device_Dashboard_Data_2024.xlsx
   January 01, 2024 - NOTE: The 'No Harm Percentage' and 'Harm Percentage' cells are calculated as the percentage of all incidents … NOTE: The 'No Harm Percentage' and 'Harm Percentage' cells are calculated as the percentage of all incidents … microbiology and pathology systems * * NOTE: The 'Percentage' cells are calculated as the percentage of all incidents … NOTE: The 'No Harm Percentage' and 'Harm Percentage' cells are calculated as the percentage of all incidents

10. Final Progress Report: Partnering With Patients To Find Adverse Events (pdf file)
    www.ahrq.gov/sites/default/files/2024-07/weingart2-report.pdf
    January 01, 2024 - A physician panel classified adverse events and service quality incidents. … a rate of 68.9 incidents per 100 admissions. … Patients who report service quality incidents may help identify patient safety hazards. … Learning from patient-reported incidents. J Gen Intern Med 2005; 20:830-36. 8. … Learning from patient-reported incidents. J Gen Intern Med 2005; 20:830-36. 17.

11. Final Progress Report: Developing Metrics for Measuring Hospital Response Capability for Mass Casualty Incidents (pdf file)
    www.ahrq.gov/sites/default/files/2024-11/mccarthy2-report.pdf
    January 01, 2024 - Final Progress Report: Developing Metrics for Measuring Hospital Response Capability for Mass Casualty Incidents … 1R13HS017577-01 Title: Developing Metrics For Measuring Hospital Response Capability For Mass Casualty Incidents … healthcare system is not adequately prepared to deal with mass casualty incidents. … to maintain service operations and achieve its response objectives during all high-priority hazard incidents … Healthcare emergency management: establishing the science of managing mass casualty and mass effect incidents

12. Medication or Other Substance Dashboard | Agency for Healthcare Research and Quality
    www.ahrq.gov/npsd/data/dashboard/medication.html
    September 01, 2025 - dashboard presents information on medication or other substance-related patient safety concerns, which span incidents … of safety concerns, and type of substance involved is presented, followed by further examination of incidents

13. Improving the Value of Patient Safety Reporting Systems (pdf file)
    www.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.

14. 2025 SOPS Nursing Home Database Report Executive Summary Overview Infographic (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/sops/databases/nursing-home/2025-nursing-home-database-report-summary.pdf
    January 01, 2025 - Respondents 63% Composite Measure Average Highest Scoring Composite Measures Communication About Incidents … safe, tell someone if they see something that might harm a resident, and talk about ways to keep incidents

15. Surveys on Patient Safety Culture (SOPS) Nursing Home Survey: 2023 User Database Report Infographic Summary (pdf file)
    www.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

16. SOPS Nursing Home Survey: What You Need To Know - Theresa Famolaro, MPS, MS, MBA (pdf file)
    www.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

17. Medication Dashboard Data 2025 (xls file)
    www.ahrq.gov/sites/default/files/wysiwyg/npsd/Medication_Dashboard_Data_2025.xlsx
    January 01, 2025 - Med_4 Stage of Origin by Incorrect Action - Incidents Med_5 Contributing Factors by Incorrect … Action - Incidents Med_6 Contributing Factors Known by Patient Age - Incidents Med_7 Contributing … Factors by Patient Age - Incidents Med_8 Incident Preventability by Patient Age - Incidents … Med_4 Med_4: Extent of Residual Harm by Incorrect Action - Incidents Incorrect Action(s) Extent of … Med_6 Med_6: Contributing Factors by Incorrect Action - Incidents Incorrect Action(s) Contributing

18. Surgical Patient Experience of Care Survey Design Project (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/surgical/about/F2CGLizHoyRogerLevine.pdf
    June 02, 2025 - 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.

19. Medication Dashboard Data 2024 (xls file)
    www.ahrq.gov/sites/default/files/wysiwyg/npsd/Medication_Dashboard_Data_2024.xlsx
    January 01, 2024 - Med_4 Stage of Origin by Incorrect Action - Incidents Med_5 Contributing Factors by Incorrect … Action - Incidents Med_6 Contributing Factors Known by Patient Age - Incidents Med_7 Contributing … Factors by Patient Age - Incidents Med_8 Incident Preventability by Patient Age - Incidents … Med_4 Med_4: Extent of Residual Harm by Incorrect Action - Incidents Incorrect Action(s) Extent of … Med_6 Med_6: Contributing Factors by Incorrect Action - Incidents Incorrect Action(s) Contributing

20. Network of Patient Safety Databases Falls Chartbook, 2023 (pdf file)
    www.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