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Showing results for "incidents".

161. 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 …

162. 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…

163. Appendix III (continued) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/report/apiiid.html
     June 01, 2010 - State Respondent: N/A Mode of Data Collection: N/A Total Items/indicators: Six categories of incidents … Testing: Field tested only Summary: Participating States provide information concerning the number of incidents … States may provide required data via NCI form titled "NCI Protocol for Reporting Incidents: Abuse and … *States are NOT identified in the final Incidents report, which is used for internal project purposes

164. 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 - Infusion Devices 329 Relationship between studies of devices and adverse event reports Adverse incidents … Cook, et al.8 and Cook and Woods9 provide examples of adverse drug infusion incidents involving these … Attempts have been made to create adverse event reporting systems to capture and analyze incidents … Features of infusion device related incidents revealed by systematic analysis of an incident reporting

165. Understanding the Bidirectional Relationship Between Depression and Heart Failure (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/decision/mcc/pathak-r01grant.pdf
     November 30, 2015 - Understanding the Bidirectional Relationship Between Depression and Heart Failure Rapid Secondary Analysis to Optimize Care for Patients with Multiple Chronic Conditions –R01 Grants Understanding the Bidirectional Relationship Between Depression and Heart Failure Original Principal Investigator: Pathak, J.…

166. Learndefects (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/learndefects.doc
     August 08, 2012 - This could include incidents that you believe caused patient harm or put patients at risk for significant

167. 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 - word-of-mouth and ad-hoc conversations, hospital and national databases, and information from local incidents … word-of-mouth and ad-hoc conversations, hospital and national databases, and information from local incidents … The survey explored perceptions of the frequency of critical incidents in NORA, gathered descriptions … of these incidents, and examined different causes (e.g., environmental, organizational, personal, … Anaesthesia provider perceptions of system safety and critical incidents in non-operating theatre anaesthesia

168. Chapter 3. Data Collection and Analysis Using TRIPS | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man3.html
     December 01, 2017 - Even in "found on floor" incidents, staff should brainstorm together to determine likely causes.

169. AHRQ Releases First Public Database on Patient Safety Events Submitted by PSOs | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsletters/e-newsletter/670.html
     June 01, 2019 - chartbook for providers and others to learn about patient safety events, including the distribution of incidents

170. TeamSTEPPS Fundamentals Course: Module 1. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps/instructor/fundamentals/module1/slintro.html
     June 01, 2019 - Incremental changes evident through reduction of nosocomial infections, falls, birth trauma, and other incidents

171. Tool 5A: Information To Include in Incident Reports | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/incident-reports.html
     January 01, 2013 - Preventing Falls in Hospitals Tool 5A: Information To Include in Incident Reports Previous Page Next Page Table of Contents Preventing Falls in Hospitals Roadmap Acknowledgments Overview Icons 1. Are you ready for this change? 2. How will you manage change? 3. Which fall prevention pra…

172. 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…

173. Final Progress Report: Impact of state policies on nursing home patient safety culture (pdf file)
     www.ahrq.gov/sites/default/files/2024-12/li-report.pdf
     January 01, 2024 - mistakes 72.4±25.3 -- -- Domain 6: handoffs 70.8±26.6 -- -- Domain 7: feedback & communication about incidents … 4.496 .083 Domain 6: handoffs 8.306 .002 9.907 <.000 Domain 7: feedback and communication about incidents … handoffs 0.98 (0.95, 1.02) [0.330] 1.00 (0.96, 1.03) [0.749] 0.810 7: feedback and communication about incidents … Mistakes 1.0164 0.6864 Domain 6: Handoffs 1.0907 0.0305* Domain 7: Feedback and Communication about Incidents

174. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/engage/references.html
     May 01, 2023 - Contributory factors to patient safety incidents in primary care: protocol for a systematic review. … The "Seven Pillars" response to patient safety incidents: effects on medical liability processes and … Multimorbidity and patient safety incidents in primary care: a systematic review and meta-analysis. … Safety incidents in the primary care office setting. Pediatrics 2015;135(6):1027-35. … Responding to patient safety incidents: the “seven pillars.”

175. Nursing Home Survey on Patient Safety Culture: 2019 User Database Report Part I (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/2019-nhsops-dbreport-parti.pdf
     January 01, 2019 - 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 … Feedback and Communication About Incidents 85% 9.39% 54% 72% 79% 86% 92% 96% 100% 3. … Feedback and Communication About Incidents When staff report something that could harm a resident, someone … (B4) 83% 10.46% 46% 69% 76% 84% 91% 95% 100% In this nursing home, we talk about ways to keep incidents

176. Nursing Home Survey on Patient Safety Culture: 2019 User Database Report Part I (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/2019-nhsops-dbreport-parti-rev091721.pdf
     January 01, 2019 - 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 … Feedback and Communication About Incidents 85% 9.39% 54% 72% 79% 86% 92% 96% 100% 3. … Feedback and Communication About Incidents When staff report something that could harm a resident, someone … (B4) 83% 10.46% 46% 69% 76% 84% 91% 95% 100% In this nursing home, we talk about ways to keep incidents

177. PS Grantee | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/index.html?page=14
     January 01, 2024 - April 2009 Developing Metrics For Measuring Hospital Response Capability For Mass Casualty Incidents

178. Fallpxtool5A (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallpxtoolkit/fallpxtool5a.docx
     January 29, 2013 - 5A: Information To Include in Incident Reports Background: The purpose of this tool is to audit incident reports of falls to see if the reports provide adequate information for root cause analysis. Alternatively, the information below may be used in conjunction with Tool 3O, “Postfall Assessment for Root Cause Analysis…

179. Final Progress Report: Communication to Prevent and Respond to Medical Injuries: WA State Collaborative (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/gallagher-report.pdf
     August 01, 2014 - in practice, put only serious-harm cases through their resolution process, we decided to make all incidents … obtained through meetings and contacts with the partner sites and analysis of case-level data on incidents … at each hospital; to compare experiences across hospitals; and to identify factors associated with incidents … Its insured physicians often did not promptly notify it when incidents occurred, and hospital risk managers … Involved personnel and their managers had difficulty getting past these incidents, and the negative

180. 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 - The main method used to report incidents consists of a paper incident report, which is completed by the … Incident types include medication errors, falls, procedure-related incidents, patient care-related incidents … , treatment-related incidents, equipment- related incidents, lost/broken patient articles, and other. … reported that, although labeling near misses in the pharmacy as “interventions” rather than as reportable incidents