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21. What Happens After a Patient Safety Event? Medical Expenditures and Outcomes in Medicare (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Encinosa.pdf
    January 01, 2003 - period the IOM report was released), we examine potentially preventable adverse medical events that occurred … The unit of observation was any major surgery admission (identified as the “index” surgery) that occurred … The surgeries occurred at 1,725 hospitals nationwide. … potentially preventable adverse medical events only cases in which the evidence that such an event occurred … Thus, there may have been many more preventable safety events (as well as close calls) that occurred

22. AHRQ Mastectomy SB Infographic v15 (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/data/infographics/double-mastectomy.pdf
    February 01, 2016 - The rise in mastectomies occurred despite breast cancer rates remaining constant. 2005 2013 Sharp

23. The Nature, Characteristics and Patterns of Perinatal Critical Events Teams (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Riley_58.pdf
    April 02, 2008 - to execute a specific task, whereas “team reformation” occurred when team membership changed in a … Each behavioral marker was scored using the following scale: • “0” Behavior occurred at or below … • “2” Behavior occurred more than 90 percent of the times when prompted by the event set. … emergency measures; and planning for an emergency intervention occurred. … Leadership transfer occurred continuously throughout an obstetrics emergency.

24. An Analysis of Nurses' Cognitive Work: A New Perspective for Understanding Medical Errors (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Potter.pdf
    January 01, 2003 - The total number of links was summarized and grouped, then the number of activities that occurred for … Calculations were made to show the cognitive load at the time each interruption occurred and at the … Omissions for RN #3 occurred with a cognitive stacking load of 16, 18, 17, and 16 respectively. … Omissions occurred at various times with respect to a nurse’s cognitive stacking measure. … For example, an omission occurred with a nurse’s cognitive stacking as low as 5 and as high as 20.

25. Preparing for Ambulatory Computerized Prescriber Order Entry by Evaluating Preimplementation Medication Errors (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Devine.pdf
    July 01, 2003 - , but the medication did not reach the patient C An error occurred that reached the patient but did … but no patient harm Error, harm E An error occurred that resulted in the need for treatment or … hospitalization and caused temporary patient harm G An error occurred that resulted in permanent … patient harm H An error occurred that resulted in a near-death event (e.g., anaphylaxis, cardiac … A 5-month time frame was identified; in an effort to minimize bias, one that occurred immediately prior

26. 5. How do you measure fall rates and fall prevention practices? | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/measure-fall-rates.html
    January 01, 2013 - With each fall, you will need to define the level of injury that occurred, if any. … The patient in whom the fall occurred. The date the fall occurred. … But for calculation of a fall rate, you need the date the fall occurred and the responsible unit (if … Rates are calculated as follows: First, count the number of falls that occurred during the month of … Try to understand why the fall occurred and how such an incident might be prevented in the future.

27. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits - Functional Specifications (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallspxspecs.pdf
    February 01, 2018 - type occurred daily. … type occurred daily. … type occurred daily. … type occurred daily. … type occurred daily.

28. Improving the Safety of Heparin Administration by Implementing a Human Factors Process Analysis (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Harder.pdf
    May 19, 2003 - Brennan et al.1 reported that adverse events occurred in 3.7 percent of the selected cases (95% confidence … Thomas et al.2 reported that in this sample, adverse events occurred at a rate of 2.9 percent (with … Death occurred in 6.6 percent (SD of 1.2 percent) of the adverse events. … in 2003.4 Not surprisingly, the results of the studies of adverse events that occurred in Utah and … This education occurred on the patient care units 24 hours a day for the 5-day process.

29. PowerPoint Presentation
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module6/module6-care-for-caregiver.pptx
    May 01, 2011 - , but they feared that an error may have occurred. … /organization recognizing event occurred. … This stage is characterized by either the second-victim realizing that an event has occurred, or the … organization recognizing that an event has occurred. … The event might produce feelings of internal inadequacy, either because the event occurred or because

30. Module 4: Event Reporting, Event Investigation and Analysis | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes4.html
    August 01, 2022 - information, other than event reports, that might provide information indicating that a CANDOR event has occurred … create a cohesive environment for informing the organization as to whether a CANDOR event may have occurred … implement the best practice of creating a hotline for staff to call when they feel a CANDOR event has occurred … Risk Management can also provide ongoing support to managers on the unit(s) where the event occurred. … Also, the location where the event occurred is generally no longer intact, so information that could

31. Module 6: Care for the Caregiver | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes6.html
    August 01, 2022 - , but they feared that an error may have occurred. … This stage is characterized by either the second-victim realizing that an event has occurred, or the … organization recognizing that an event has occurred. … The second-victim might not be able provide care in the room where the event occurred and might appear … The event might produce feelings of internal inadequacy, either because the event occurred or because

32. Conducting a Morning Briefing | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/hai/cusp/toolkit/morning-briefing.html
    December 01, 2012 - This tool provides a structured approach to help physicians and nurses identify the problems that occurred … If an adverse event occurred, you should also use the Learn From Defects Form.

33. PowerPoint Presentation
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/module5-response-disclosure-notes.pptx
    August 21, 2015 - The patient and/or family have a reasonable expectation to be informed when a harm event has occurred … of this initial conversation is to advise the patient and/or family that an adverse event may have occurred … Investigation and Analysis, the disclosure should include – An explicit statement that an event has occurred … During disclosure, patients and families generally want a clear, explicit statement that an event has occurred … If the event was preventable and occurred due to error, the communicator should: Consider using the word

34. Mod5-Disclosure-Checklist (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/mod5-disclosure-checklist.pdf
    April 01, 2016 - after the CANDOR event is identified, advise the patient and/or family that an adverse event may have occurred … ■ Explain what is known about why the adverse event occurred; do not speculate.

35. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/measuredesc-dailyearlymobility-facguide.docx
    January 01, 2017 - physical or occupational therapist, and finally, whether any adverse events associated with mobilization occurred … and, if so, what types of events occurred. … Slide 28 Events SAY: The next columns are designed to help track any adverse events that might have occurred … This field allows you to document up to three events if multiple events occurred. … Slide 29 Event Codes SAY: If no adverse events occurred, use “0” (the code for “none”) to indicate

36. USER GUIDE: Personal Protective Equipment (PPE) COVID-19 Observational Audit Data Tracking Tool for Use in Skilled Nursing Facilities (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/ppe-covid19-audit-tracking-tool-userguide.pdf
    April 01, 2021 - enter the location within your facility where the observational audit of the employee’s PPE activity occurred … Next enter the date the audit occurred using the month/day/four-digit year format in Column E. … Select the time block that aligns with the time the audit occurred for the employee observed.

37. USER GUIDE: Hand Hygiene Observational Audit Data Tracking Tool for Use in Skilled Nursing Facilities (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/hand-hygiene-audit-tool-userguide.pdf
    April 01, 2021 - location within your facility where the observational audit of the employee’s hand hygiene activity occurred … Next enter the date the audit occurred using the month/day/four-digit year format in Column E. … Select the time block that aligns with the time the audit occurred for the employee observed.

38. Objective Outcomes Data Collection Tool | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/hai/tools/mvp/modules/vae/objective-outcome-tool.html
    January 01, 2017 - Total number of episodes of mechanical ventilation How many episodes of mechanical ventilation have occurred … Total number of deaths How many deaths have occurred in the patients who have been or were mechanically

39. Transformation to the Patient-Centered Medical Home in CareOregon Clinics (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/tpc/tpc-profile-meenan.pdf
    April 01, 2015 - Qualitative interviews with organizational leaders revealed that implementation occurred in two distinct … At 1 year post-implementation, 5.39 fewer inpatient admissions per month occurred in the PCR clinics

40. Measure Descriptions for Daily Early Mobility: Facilitator Guide | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/hai/tools/mvp/modules/technical/daily-early-mobility-fac-guide.html
    February 01, 2017 - physical or occupational therapist, and finally, whether any adverse events associated with mobilization occurred … and, if so, what types of events occurred. … 29: Events Say: The next columns are designed to help track any adverse events that might have occurred … This field allows you to document up to three events if multiple events occurred. … Slide 30: Event Codes Say: If no adverse events occurred, use "0" (the code for "none") to indicate