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121. 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?

122. 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

123. 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

124. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45009/psn-pdf
     March 30, 2016 - https://psnet.ahrq.gov/issue/fatal-mistakes Health professionals involved in medical errors experience … psnet.ahrq.gov/issue/medical-error-second-victim https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events … suffering-silence-qualitative-study-second-victims-adverse-events https://psnet.ahrq.gov/issue/supporting-involved-health-care-professionals-second-victims-following-adverse-health-event

125. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44645/psn-pdf
     July 01, 2017 - post-traumatic-stress-disorder-amongst-surgical-trainees-unrecognised-risk Physicians who experience adverse effects after being involved … post-traumatic-stress-disorder-amongst-surgical-trainees-unrecognised-risk https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events … https://psnet.ahrq.gov/issue/medical-error-second-victim https://psnet.ahrq.gov/issue/supporting-involved-health-care-professionals-second-victims-following-adverse-health-event

126. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/846563/psn-pdf
     March 21, 2023 - Healthcare workers involved in a medical error or adverse event may experience a range of emotional … Healthcare staff involved in an adverse event can develop post-traumatic stress disorder (PTSD) with … Staff who are involved in continual system failures may want to avoid bringing attention to more problems … Counteract Burnout Addressing burnout is paramount to ensuring support for healthcare workers involved … Editor’s Note: Many resources refer to healthcare workers involved in a medical error as the “second

127. 164-Cusp-Meeting-Pre-Work (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/164-cusp-meeting-pre-work.docx
     June 02, 2025 - There are many ways to keep the Senior Executive involved with your CUSP team and with your unit. … Also, invite the Senior Executive to visit the unit or to attend Executive Walk Rounds to keep them involved

128. The Role of Patient Safety in the Device Purchasing Process (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Johnson.pdf
     January 01, 2004 - patient safety considerations are incorporated into medical device purchasing decisions, individuals involved … First, individuals involved in the purchasing decisions were questioned using a structured interview … All subjects were involved, albeit to different extents, in the latest purchase of infusion pumps at … Those directly involved in the decisions at Sites 1 and 2 felt the best decision was made. … This indicated some awareness of the human factors issues involved with device use safety.

129. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866350/psn-pdf
     July 24, 2024 - living-aftermath-second-victim-experience-among-certified-registered-nurse- anesthetists Many healthcare staff who are involved … living-aftermath-second-victim-experience-among-certified-registered-nurse-anesthetists https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events

130. CDSiC Operations Center Charter - Base Period | CDSiC
     cdsic.ahrq.gov/cdsic/cdsic-operations-center-charter
     April 30, 2022 - and Coordinating CDS Resources News CDSiC Leadership Viewpoints Get Involved … Constraints and potential challenges related to Operations Center activities  Relevant stakeholders who are involved … GET INVOLVED IN CDSiC BY: Signing up for the CDSiC Insider newsletter Expressing interest … joining a CDSiC Workgroup Sharing your feedback and/or questions with the CDSiC team Get Involved

131. CDSiC Innovation Center Charter - Base Period | CDSiC
     cdsic.ahrq.gov/cdsic/innovation-center-charter-bp
     April 30, 2022 - and Coordinating CDS Resources News CDSiC Leadership Viewpoints Get Involved … Constraints and potential challenges related to Innovation Center activities Relevant stakeholders who are involved … GET INVOLVED IN CDSiC BY: Signing up for the CDSiC Insider newsletter Expressing interest … joining a CDSiC Workgroup Sharing your feedback and/or questions with the CDSiC team Get Involved

132. CDSiC Stakeholder and Community Outreach Center Charter - Base Period | CDSiC
     cdsic.ahrq.gov/cdsic/stakeholder-community-outreach-center-charter
     April 30, 2022 - and Coordinating CDS Resources News CDSiC Leadership Viewpoints Get Involved … Constraints and potential challenges related to Stakeholder Center activities Relevant stakeholders who are involved … GET INVOLVED IN CDSiC BY: Signing up for the CDSiC Insider newsletter Expressing interest … joining a CDSiC Workgroup Sharing your feedback and/or questions with the CDSiC team Get Involved

133. Choosing Quality Measures | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/quality-resources/tools/chtoolbx/choosing/index.html
     June 01, 2020 - and usefulness of quality measurement activities without overly taxing the resources of all parties involved … Factors to Consider Many factors are involved in choosing which quality measures to use, whatever the … If only one entity is involved, almost any quality measure can be used, provided that a rigorous and … If multiple entities are involved, the use of measures with rigorous and precise specifications is more

134. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44316/psn-pdf
     March 20, 2017 - how a second victim intervention program participating with a PSO can provide support for clinicians involved … new-patient-safety-organizations-lower-roadblocks-medical-error-reporting https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events … https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events https

135. Choosing Quality Measures (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/chtoolbx/choosing/choosing.doc
     June 02, 2025 - and usefulness of quality measurement activities without overly taxing the resources of all parties involved … Return to Contents Factors to Consider Many factors are involved in choosing which quality measures … If only one entity is involved, almost any quality measure can be used, provided that a rigorous and … If multiple entities are involved, the use of measures with rigorous and precise specifications is more

136. What Is the Environment for Reporting on Health Care Quality? | Agency for Healthcare Research and Quality
     www.ahrq.gov/talkingquality/plan/environment.html
     June 01, 2016 - It can be helpful to document what you know about them so that everyone involved is clear on who will … Questions about purchasers and regulators: Among health care purchasers, who (if anyone) is most involved … Is a State agency or other regulatory body involved in quality measurement and reporting in your marketplace … Do you have the expertise in-house for all of the steps involved in effective reporting?

137. The impact of perioperative catastrophes on anesthesiologists: results of a national survey. | PSNet
     psnet.ahrq.gov/issue/impact-perioperative-catastrophes-anesthesiologists-results-national-survey
     August 27, 2009 - The term " second victim " was coined to describe clinicians who are involved in medical errors, acknowledging … This study surveyed anesthesiologists and found that 84% of respondents were involved in at least one … that support providers at the time of the event and thereafter to help manage the emotional burden involved

138. CDSiC Year 3 Period of Performance Report | CDSiC
     cdsic.ahrq.gov/cdsic/year3-period-performance-report
     September 30, 2024 - and Coordinating CDS Resources News CDSiC Leadership Viewpoints Get Involved … GET INVOLVED IN CDSiC BY: Signing up for the CDSiC Insider newsletter Expressing interest … joining a CDSiC Workgroup Sharing your feedback and/or questions with the CDSiC team Get Involved

139. Slide 1 (pdf file)
     effectivehealthcare.ahrq.gov/sites/default/files/cf__deliberativemethodswebinar_deliberativemethodsexperiment.pdf
     June 01, 2012 - to find this information ─ http://www.effectivehealthcare.ahrq.gov/tools-and- resources/how-to-get-involved-in-the-effective-health-care … and information to look for http://www.effectivehealthcare.ahrq.gov/tools-and-resources/how-to-get-involved-in-the-effective-health-care-program … / http://www.effectivehealthcare.ahrq.gov/tools-and-resources/how-to-get-involved-in-the-effective-health-care-program … / http://www.effectivehealthcare.ahrq.gov/tools-and-resources/how-to-get-involved-in-the-effective-health-care-program

140. Shadowing (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/shadowing.doc
     June 02, 2025 - · All staff involved in the delivery of patient care in units with poor Safety Attitude Questionnaire … What happened during the shadowing exercise that involved multiple practice domains? … Did the providers involved seek help from a supervisor? Yes No N/A 6.