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Showing results for "involved".

21. CRP Certification: Promoting Accountability and Learning After Adverse Events (pdf file)
    www.ahrq.gov/sites/default/files/2024-07/gallagher5-report.pdf
    January 01, 2024 - If a case is certified, the involved physician licensee or healthcare organization acting on their behalf … Finally, it is possible that the involved states may not be representative of all state medical boards … Seventy percent of the Washington cases involved severe harm, including nine death cases. … Two thirds of the cases involved severe harm, including two death cases. … in any of this discussion and one of my observations is that the discussion has involved a variety

22. Strategy 3: Nurse Bedside Shift Report (Tool 1) (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy3/Strat3_Tool_1_BSR_Broch_508.docx
    June 02, 2025 - How can you get involved? … This brochure explains what nurse bedside shift report is and how you can get involved. … At [insert hospital name], we want you to be involved in shift changes to make sure you get high-quality

23. Resources for Developers of Quality Reports for Consumers | Agency for Healthcare Research and Quality
    www.ahrq.gov/talkingquality/resources/index.html
    September 01, 2019 - Organizations Involved in Quality Reporting Review this list of key initiatives by the many organizations … involved in efforts to measure, report, and improve the quality of healthcare.

24. A-10. Measure 7: Information about area (community) resources is offered by clinician | Agency for Healthcare Research and Quality
    www.ahrq.gov/prevention/resources/chronic-care/ccrm-atlas-suppl/ccrm-apptabA-10.html
    October 01, 2013 - clinician-patient Instrument: Wrap-Around Observation Manual – Second Version Purpose: For families involved … resource/intervention (e.g., A.A, vocational rehab, Teammates) to the parent or asks if the parent is involved … “Yes” if the team mentions or asks if the parent is involved in resources/interventions. … “Yes” if the team asks about or mentions resources/interventions and the parent is already involved or

25. 129-Ss-Blank-Lfd (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/129-ss-blank-lfd.docx
    April 01, 2025 - All staff involved in the delivery of care related to a defect should be present when this defect is … For this investigation, put yourself in the place of those involved and in the middle of the event as … Determine factors that may have contributed to the defect and evaluate whether each one was involved. … If involved, did it negatively contribute (increase harm) or positively contribute (reduce impact of … Ask frontline staff involved in the defect whether the interventions reduced the likelihood of recurrence

26. System-Focused Event Investigation and Analysis Guide | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4.html
    August 01, 2022 - First, it diverts attention away from factors in the system (other than the involved individual) that … The standard solution is to blame the people involved. … Consider interviewing others who were around, but not directly involved in the event. … This is especially important for individuals who were directly involved in the event. … Technology involved (e.g., any usability issues, downtime, individual knowledge gaps).

27. Exhibit 4.15. Project Team Composition—Electronic Prescribing | Agency for Healthcare Research and Quality
    www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit4-15.html
    November 01, 2014 - Horizon Hospital—Lakeview Healthcare This project involved eight staff: Facilitator

28. Building the Business Case for CANDOR Worksheet | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/worksheet2.html
    August 01, 2022 - Identification of the clinical areas involved in the rollout and the key stakeholders, as well as the … Include a description of who needs to be involved to support the project; what is needed in terms of … Performance measures to be compared include: Dollars involved in settlements. … Dollars involved in actual suits. Median and average payment to claimants.

29. Implementation Guide for the CANDOR Process: Appendix A | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/impguide/apa.html
    August 01, 2022 - Identification of the clinical areas involved in the rollout and the key stakeholders, as well as the … Include a description of who needs to be involved to support the project; what is needed in terms of … Performance measures to be compared include: Dollars involved in settlements. … Dollars involved in actual suits. Median and average payment to claimants.

30. Blood and Blood Product Dashboard | Agency for Healthcare Research and Quality
    www.ahrq.gov/npsd/data/dashboard/blood.html
    September 01, 2024 - This dashboard details the type of blood product involved, type of blood product by residual harm to

31. Appendix A. Facility Personnel Spreadsheet - Implementation Guide | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/implementation-guide/app-a.html
    May 01, 2017 - Facility Personnel Spreadsheet - Implementation Guide Insert the names of everyone who will be involved

32. Learn from Defects Tool | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/cusp/toolkit/learn-defects.html
    December 01, 2012 - All staff involved in the delivery of care related to a defect should be present when this defect is … For this investigation, put yourself in the place of those involved and in the middle of the event as … Please read each contributing factor and evaluate whether it was involved. … If it was involved, did it negatively contribute (increase harm) or positively contribute (reduce impact … Ask frontline staff involved in the defect whether the interventions reduced the likelihood of recurrence

33. Exhibit 4.12. Project Team Composition—UTI Reduction | Agency for Healthcare Research and Quality
    www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit4-12.html
    November 01, 2014 - Horizon Hospital—Lakeview Healthcare This project involved 10 staff: Facilitator:

34. Medication or Other Substance Dashboard | Agency for Healthcare Research and Quality
    www.ahrq.gov/npsd/data/dashboard/medication.html
    September 01, 2024 - At-a-glance information on description of safety concerns, origin of safety concerns, and type of substance involved

35. Exhibit 5.13. Project Team Composition—Pediatric Continuity of Care | Agency for Healthcare Research and Quality
    www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit5-13.html
    November 01, 2014 - Horizon Hospital—Lakeview Healthcare Project involved 14 staff: Executive sponsor

36. Strategy 2: Communicating to Improve Quality (Tool 2) (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy2/Strat2_Tool_2_ComTipsBroch_508.pdf
    June 02, 2025 - Tip 4: Tell us who your family members or friends are and how you want them to be involved Your … change in your condition • Find a nurse when help is needed urgently Tell us who you want to be involved … Tip 4: Tell us who your family members or friends are and how you want them to be involved Remember

37. Physician-Reported Adverse Events and Medical Errors in Obstetrics and Gynecology (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-November_45.pdf
    January 01, 2007 - Events characterized as “none of the above” usually involved administrative issues with no clinical … Seven events (9 percent) resulted in patient harm (AEs), while most involved a potential AE (46 percent … Numerous potential AEs involved lab work delays related to orders not entered, orders not acknowledged … Eleven cases (11 percent) involved process issues in making a Diagnosis, and the same number (11 cases … Although only a few minutes per day are involved, this time has significant value for busy clinicians

38. Gap Analysis Facilitator's Guide: Appendix B | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/apb.html
    August 01, 2022 - Have the staff had training related to the vulnerabilities of caregivers involved in harm events? … Do individuals directly involved in events undergo a "fitness for work" assessment? … Is followup provided for staff involved in harm events?

39. Medication Discrepancies and Potential Adverse Drug Events During Transfer of Care from Hospital to Home | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/reports/liability/neumiller.html
    August 01, 2017 - Medication classes most commonly involved in potential ADEs are displayed in Table 1. … Medication discrepancies determined to contribute to serious potential ADEs involved the antineoplastic … Potential ADEs ascribed a significant rating often involved opioids, antihypertensives, anticoagulants … Medications commonly involved in discrepancies assessed to have insignificant consequences involved acetaminophen … The involved medicines were anticoagulants or antiplatelets (e.g., enoxaparin, warfarin, dipyridamole

40. Findings | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/reports/candor-demo-program/plan-grants/findings.html
    August 01, 2022 - None of the discrepancies involved permanent disability or death, but almost half of the discrepancies … involved symptoms or temporary disability, of which 16 percent were judged to require an office visit … Cases involved discharge from one of four hospital sites affiliated with the academic medical center. … Notably, almost half (299 of 632) of reported near misses involved office processes. … In the first part of the study, researchers surveyed patients and medical staff involved in 41 claims