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Showing results for "incidents".

81. 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

82. 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

83. 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.

84. 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

85. 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.”

86. 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

87. 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

88. 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

89. Blood Dashboard Data 2025 (xls file)
    www.ahrq.gov/sites/default/files/wysiwyg/npsd/Blood_Dashboard_Data_2025.xlsx
    January 01, 2025 - They include the frequencies of report type (i.e., Incidents, Near misses, and Unsafe conditions), type

90. 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

91. 114-Mrsa-Prevention-Learning-From-Defects (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/114-mrsa-prevention-learning-from-defects.docx
    October 01, 2024 - This could include incidents that you believe caused patient harm or put patients at risk for significant

92. Developing a Taxonomy of Anesthetists’ Nontechnical Skills (ANTS) (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Patey.pdf
    January 01, 2004 - Critical incident studies in anesthesia have found that around 80 percent of reported incidents involve … assessment and giving feedback; only if video recordings are available; to debrief/discuss critical incidents … Errors, incidents and accidents in anaesthetic practice. An analysis of 2,000 incident reports. … Anesthesia crisis resource management training: teaching anesthesiologists to handle critical incidents

93. Suicide Risk Response: Enhancing Patient Safety Through Development of Effective Institutional Policies (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Bonner.pdf
    January 01, 2004 - The issues discussed included what types of incidents were of concern (e.g., any spontaneous mention … personnel includes a clearly defined chain of responsibility,” “follow-up procedures are defined,” and “incidents … incident 2.4 3.5 A documentation form is individually created by the site/program 3.2 2.875 Incidents … are documented in the progress note 5 4.625 Incidents are documented in a computer system designed

94. 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

95. Physician and Staff Engagement: Facilitator Guide | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/mvp/modules/cusp/physician-staff-engagement-facguide.html
    March 01, 2017 - Say: Industries and companies that have higher levels of staff engagement have fewer safety incidents … meta-analysis conducted in 2012 by Gallup, the same New York Times article reported 48 percent fewer safety incidents

96. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/physician-staff-engagement-facguide.docx
    January 01, 2017 - SAY: Industries and companies that have higher levels of staff engagement have fewer safety incidents … meta-analysis conducted in 2012 by Gallup, the same New York Times article reported 48 percent fewer safety incidents

97. Mercy Health Uses AHRQ's Patient Safety Culture Survey and TeamSTEPPS® to Enhance Care | Agency for Healthcare Research and Quality
    www.ahrq.gov/news/newsroom/case-studies/201411.html
    August 01, 2014 - Mercy also replaced patient beds to reduce incidents of pressure ulcers and to promote patient and staff

98. Artificial Intelligence Tool Shows Strong Performance in Predicting Patient Deterioration During Pandemic | Agency for Healthcare Research and Quality
    www.ahrq.gov/news/newsletters/e-newsletter/922.html
    July 01, 2024 - Systematic review of types of safety incidents and the processes and systems used for safety incident

99. Diagnostic Stewardship in Action | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-dx-stewardship6.html
    August 01, 2024 - While inappropriate transfusion may reflect mismanagement of a correctly diagnosed patient, such incidents

100. National Action Alliance Webinar June 18, 2024: Empowering Patient Voice in Safety Strategies (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/action-alliance-webinar-june-2024.pdf
     January 01, 2024 - Children’s Snapshot Simplified View of our Journey Key Factors Serious Safety Event Rate Rate of DART Incidents