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Showing results for "incidents".

81. NPSD Data Spotlight - Patient Safety and COVID-19: A Qualitative Analysis of Concerns During the Public Health Emergency (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-ptsafety-and-covid-19.pdf
    November 01, 2021 - policies and procedures, and treatment methods that may have contributed to specific pressure injury incidents … Additionally, several incidents were described where backup devices were unavailable due to use with … Blood and Blood Product Among the blood and blood product concerns (n = 10; 3.3%), there were three incidents … For incidents that involved a patient, the PSOs reported patient age and sex for 26 (8.6%) records,

82. SOPS Nursing Home Survey Version 2.0 Items and Composite Measures (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursing-home-items-composite-measures-english-2.0.pdf
    June 05, 2025 - This nursing home makes changes to prevent the same incidents from happening again.

83. Final Progress Report: Oral Chemotherapy Safety in Ambulatory Oncology: A Proactive Risk Assessment (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/weingart-report.pdf
    January 01, 2024 - Administration (FDA) and Institute for Safe Medication Practices (ISMP); by eliciting de-identified incidents … Sources of oral chemotherapy event reports Source Dates of Search Source Detail Number of Incidents … center 177 (25.2) 50 (25.9) 127 (25.0) Incident Reports 12/3/03 – 3/25/08 Staff-reported incidents … Incidents derived from the literature search and hospital incident reporting system included a larger … The strengths of the study include the variety of sources used to identify oral chemotherapy-related incidents

84. Appendix A: References and Available Abstracts | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/shuttered/acfselection/appendixa.html
    July 01, 2018 - The aim of this article is to review the characteristics of contingency plans for mass-casualty incidents … "Reduction in critical mortality in urban mass casualty incidents: analysis of triage, surge, and resource … guided missiles directed into the Pentagon and New York's Twin Towers in 2001 (9/11) and the tragic incidents … Comprehensive disaster responses include addressing the unique needs of children during mass-casualty incidents … The health care system must respond to disasters of all types, whether the incidents occur in urban or

85. Final Progress Report: Communication to Prevent and Respond to Medical Injuries: WA State Collaborative (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/gallagher1-report.pdf
    January 01, 2024 - 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

86. Hospital Evacuation Decision Guide (Table 6) | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/shuttered/hospevactab6.html
    July 01, 2018 - Have any other incidents occurred that increase the likelihood that an evacuation order will be issued

87. 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

88. Gap Analysis Facilitator's Guide: Appendix C | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/apc.html
    August 01, 2022 - Is a risk manager available at all times to respond to patient safety incidents?        

89. 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

90. 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

91. Chapter 4. Results | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/shuttered/acfselection/chapter4.html
    July 01, 2018 - In the case of small incidents, one person may be able to perform multiple functions. … Incidents can, for example, include major disasters, emergencies, terrorist attacks, terrorist threats … integrated organizational structure that reflects the complexity and demands of single or multiple incidents … It is used for all kinds of emergencies and is applicable to small as well as large and complex incidents … Mitigation measures are often informed by lessons learned from prior incidents.

92. Final Progress Report: APPLIED STRATEGIES FOR IMPROVING PATIENT SAFETY (ASIPS) (pdf file)
    www.ahrq.gov/sites/default/files/2024-02/pace-report.pdf
    January 01, 2024 - colleagues reviewed malpractice incident reports from primary care offices.2 Though a low number of incidents … incident reporting system such as ours, which allows a more detailed examination of error-related incidents … analysis of data from secondary sources were critical for the ASIPS project to assess the specific incidents … were tested by researchers to see if they could identify consistencies or “matches” between reported incidents … Reported incidents, alone, did not provide the full picture of errors or error-related outcomes.

93. 2025 AHRQ Surveys on Patient Safety Culture® (SOPS®) Nursing Home Survey Version 2.0 Pilot Test Results: Appendix—Results by Respondent Characteristics (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/2025-nursing-home-20-pilot-test-results-appendix.pdf
    January 01, 2025 - Learning (e.g., the nursing home looks for ways to improve resident safety and makes changes to prevent incidents … (Item A8) 87% 86% 75% 79% 71% 90% 90% This nursing home makes changes to prevent the same incidents … (Item A8) 70% 80% 72% 87% This nursing home makes changes to prevent the same incidents from happening … (Item A8) 83% 82% 79% This nursing home makes changes to prevent the same incidents from happening … (Item A8) 83% 78% 73% 83% 85% This nursing home makes changes to prevent the same incidents from

94. 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.”

95. 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

96. 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

97. 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

98. 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

99. 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

100. Appendix III (continued) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/report/apiiii.html
     June 01, 2010 - Human Services Use history: In 2005 the Division created an automated system for reporting unusual incidents … the Division created two annual reports with statistics on the aggregate data collected on types of incidents … Using: South Dakota Psychometric Testing: Not specified Summary: The Division monitors unusual incidents … on an ongoing basis by collecting data on incidents of unplanned medical attention sought, law enforcement