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Showing results for "incidents".

181. Final Progress Report: Comprehensive Analysis of Data from Testing the Re-engineered Hospital Discharge (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/chetty-report.pdf
     January 01, 2024 - Final Progress Report: Comprehensive Analysis of Data from Testing the Re-engineered Hospital Discharge Final Progress Report Title of Project: Comprehensive Analysis of Data from Testing the Re-engineered Hospital Discharge Principal Investigator and Team Members: Veerappa K. Chetty, PhD Organization: Boston M…

182. V-C3.01 Information Technology Security Policy Manual (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/data/AHRQ-Security-and-Privacy-Language-for-Information-and-Information-Technology-Procurements.pdf
     November 07, 2023 - every device it operates and authorizes for Government use, and can prevent, detect, and respond to incidents … requested images, log files, and event information to facilitate rapid resolution of sensitive information incidents … learned; and • Explanation of the mitigation steps of exploited vulnerabilities to prevent similar incidents

183. Improving Patient Safety in Hospitals: A Resource List for Users of the AHRQ Hospital Survey on Patient Safety Culture (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospitalresourcelist.pdf
     January 01, 2019 - United Kingdom determine a fair and consistent course of action toward staff involved in patient safety incidents … Tree supports the aim of creating an open culture, where employees feel able to report patient safety incidents … cause analysis to: • Identify causes and contributing factors of a sentinel event or a cluster of incidents … Implement risk reduction strategies that decrease the likelihood of a recurrence of the event or incidents

184. On-line Patient Safety Climate Survey: Tool Development and Lessons Learned (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Connelly.pdf
     January 01, 2003 - for their own mistakes. 2.23 .757 Disagree 14. are willing to report near miss/close call patient incidents … error. 7. regularly report clinical errors. 14. are willing to report near miss/close call patient incidents … Hospital safety climate and its relationship with safe work practices and workplace exposure incidents

185. Saving Lives and Saving Money: Hospital-Acquired Conditions Update - Interim Data From National Efforts To Make Care Safer, 2010-2014 (pdf file)
     www.ahrq.gov/sites/default/files/publications2/files/interimhacrate2014_cx.pdf
     November 19, 2015 - As a result of the reduction in the rate of HACs, we estimate that approximately 790,000 fewer incidents … Cumulatively, approximately 2.1 million fewer incidents of harm occurred in 2011, 2012, 2013, and 2014

186. Breaking Down Barriers to Aseptic Catheter Insertion | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/archived-webinars/breaking-down-barriers-slides.html
     December 01, 2017 - The CAUTI rates trend downward to zero incidents in March 2015.

187. Tool: SSA (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/head-bed-elevation-litreview.docx
     January 01, 2017 - Tool: SSA Summary The elevation of the head of bed (HOB) to a semirecumbent position (at least 30 degrees) is associated with a decreased incidence of aspiration and ventilator-associated pneumonia (VAP). The intervention is supported unanimously by all four leading guidelines, and newer publications in the field acc…

188. How To Measure Pressure Injury Rates and Prevention Practices
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module5/module5_pressureinjury-msmt_slides.pptx
     June 02, 2025 - How To Measure Pressure Injury Rates and Prevention Practices How To Measure Pressure Injury Rates and Prevention Practices ADD Hospital Name Here Module 5 1 Basic Quality Improvement Principle If you can’t measure it, you can’t improve it. 2 2 Quality Improvement Principle Pressure injury rates and preven…

189. NICU Family Information Packet, Appendix B, Vision Screening and Retinopathy (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-vision.pdf
     June 02, 2025 - NICU Family Information Packet, Appendix B, Vision Screening and Retinopathy Vision Screening and Retinopathy of Prematurity Visual Deficits Seen in Preterm Infants ■ High-risk infants are more likely to have permanent visual deficits and/or show a delay in visual development that persists until adolescence. ■ …

190. Chapter-6 - Carbapenem-Resistant-Enterobacteriaceae (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/cre.pdf
     September 26, 2019 - Chapter-6 - Carbapenem-Resistant-Enterobacteriaceae Carbapenem-Resistant Enterobacteriaceae 6-1 6. Carbapenem-Resistant Enterobacteriaceae Authors: Elizabeth Gall, M.H.S., and Anna Long, M.P.H. Reviewer: Caroline Logan, Ph.D., and Pranita Tamma, M.D. Introduction Background Carbapenem-resistant Enterobacteria…

191. Appendix A. Grantee Profiles | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/demo-program/grants/appa.html
     August 01, 2022 - The analysis included 637 onsite incidents. … Successful remediation of patient safety incidents: A tale of two medication errors. … The “Seven Pillars” response to patient safety incidents: Effects on medical liability processes and … Notably, all incidents of unanticipated harm were eligible for the CRP, not only cases of serious harm … Further, incidents of shoulder dystocia and fetal distress decreased 50% (Santos, Ritter, Hefele, et

192. Improving Patient Safety in Hospitals: A Resource List for Users of the AHRQ Hospital Survey on Patient Safety Culture (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospital-version-2-resource-list.pdf
     December 01, 2024 - The Incident Decision Tree: Guidelines for Action Following Patient Safety Incidents https://www.ahrq.gov … United Kingdom determine a fair and consistent course of action toward staff involved in patient safety incidents … Survey Version 2.0 Resource List 11 open culture, where employees feel able to report patient safety incidents … and Quality Improvement The Incident Decision Tree: Guidelines for Action Following Patient Safety Incidents

193. Final Report: Using Risk Models To Improve Safety With Dispensing High-Alert Medications in Community Pharmacies (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/cohen-report.pdf
     January 01, 2024 - Final Report: Using Risk Models To Improve Safety With Dispensing High-Alert Medications in Community Pharmacies Final Report: Using Risk Models to Improve Safety with Dispensing High-Alert Medications in Community Pharmacies Principal Investigator: Michael R. Cohen, RPh, MS, ScD Team Members: Judy L. Smetzer, R…

194. Learn From Defects Tool (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/tools/applying-cusp/learn_from_defects.docx
     December 01, 2017 - Learn From Defects Tool AHRQ Safety Program for Surgery Learn From Defects Tool – Perioperative Setting What is a defect? A defect is any event or situation that you don’t want to repeat. This could include an incident that caused patient harm or put patients at risk for harm, such as a patient fall. Problem statem…

195. Improving Patient Safety in Community Pharmacies: A Resource List for Users of the AHRQ Community Pharmacy Survey on Patient Safety Culture (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/community-pharmacy/pharmacy-resources.pdf
     May 01, 2023 - United Kingdom determine a fair and consistent course of action toward staff involved in patient safety incidents … Tree supports the aim of creating an open culture, where employees feel able to report patient safety incidents

196. Summary Background Report on 2013 Retirement of Measures from the Child Core Set (pdf file)
     www.ahrq.gov/sites/default/files/publications2/files/measure-retirement-2013.pdf
     January 01, 2013 - Summary Background Report on 2013 Retirement of Measures from the Child Core Set Summary Report Background Report on 2013 Retirement of CHIPRA Measures from the Child Core Set Prepared for: Agency for Healthcare Research and Quality Rockville, MD Prepared by: RTI International Resear…

197. Final Progress Report: Medication Error Reduction, Technologies and Human Factors (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/carayon-report.pdf
     January 01, 2024 - nurse The web-based error reporting system also provided a mechanism for identifying IV medication incidents … To ensure follow-up and documentation, the IV pump nurse maintained a log of pump-related incidents … Over time, the incidents reported to the coordinator were summarized according to categories of the … This summary report facilitated organized follow up when recurring incidents or types of problems arose

198. Final Progress Report: Implementing Reduced Work Hours for All House Staff To Improve Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/landrigan2-report.pdf
     January 01, 2024 - percutaneous injuries (i.e., injuries from needle sticks and scalpel laceration), and ‘fall-asleep’ incidents … events: 1) Direct Observation: Direct observation on morning rounds was the first method for detecting incidents … Data collected for incidents included description of the event, classification of the event, where the … Medication incidents also included name, dose, route and category of the drug involved, type of error

199. Cost Effectiveness of a Multifaceted Program for Safe Patient Handling (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Siddharthan.pdf
     January 10, 2005 - Cost Effectiveness of a Multifaceted Program for Safe Patient Handling 347 Cost Effectiveness of a Multifaceted Program for Safe Patient Handling Kris Siddharthan, Audrey Nelson, Hope Tiesman, FangFei Chen Abstract Objective: The Patient Safety Center in the Veterans Health Administration (VHA) introduced …

200. Module 5: How To Measure Pressure Injury Rates and Prevention Practices | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/workshop/slides5.html
     October 01, 2017 - Module 5: How To Measure Pressure Injury Rates and Prevention Practices Slide Presentation Slide 1: How To Measure Pressure Injury Rates and Prevention Practices ADD Hospital Name Here Module 5 Slide 2: Basic Quality Improvement  Principle If you can’t measure it, you can’t improve it. Image: Pu…