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patientregistry.ahrq.gov/news/newsletters/e-newsletter/908.html
April 01, 2024 - Home
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Surge in Drug Shortages Occurred … Newsletter
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Surge in Drug Shortages Occurred … Today's Headlines:
Surge in Drug Shortages Occurred in Wake of Pandemic, Study Finds
April 23 Webinar … Surge in Drug Shortages Occurred in Wake of Pandemic, Study Finds
A recent AHRQ-funded study on pharmaceutical … 2024
Page originally created April 2024
Internet Citation: Surge in Drug Shortages Occurred
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patientregistry.ahrq.gov/hai/pfp/2015-interim.html
December 01, 2016 - over the 5 years (2011, 2012, 2013, 2014, and 2015) relative to the number of HACs that would have occurred … precise causes of the decline in patient harm are not fully understood, the increase in safety has occurred … in 2015 than would have occurred if the rate of HACs had remained steady at the 2010 level ( Exhibit … Cumulatively, approximately 3.1 million fewer incidents of harm occurred in 2011, 2012, 2013, 2014, and … on October 1, 2015, and also due in part to delays in contracting for MPSMS data analysis that occurred
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patientregistry.ahrq.gov/hai/pfp/2014-final.html
January 01, 2018 - precise causes of the decline in patient harm are not fully understood, the increase in safety has occurred … in 2014 than would have occurred if the rate of HACs had remained steady at the 2010 level ( Exhibit … Cumulatively, approximately 2.1 million fewer incidents of harm occurred in 2011, 2012, 2013, and 2014 … Most of the deaths averted occurred as a result of reductions in the rates of pressure ulcers and adverse … An estimated 2.1 million fewer HACs were experienced by patients from 2010 to 2014 than would have occurred
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patientregistry.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/2014FinalHACreport4Web-13Dec2016.pdf
December 01, 2016 - patients over the 4 years (2011, 2012, 2013, and 2014) relative to the number of HACs that
would have occurred … precise causes of the decline in patient harm are not fully understood, the increase
in safety has occurred … the reduction in the rate of
HACs, we estimate that approximately 798,000 fewer incidents of harm occurred … in 2014 than
would have occurred if the rate of HACs had remained steady at the 2010 level (Exhibit … Cumulatively, approximately 2.1 million fewer incidents of harm occurred in 2011, 2012, 2013,
and 2014
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patientregistry.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
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patientregistry.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
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patientregistry.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.
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patientregistry.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.
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patientregistry.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/notes.html
August 01, 2022 - 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 … During disclosure, patients and families generally want a clear, explicit statement that an event has occurred … what happened in a way that is easy to understand, explain what is known about why the adverse event occurred … If the event was preventable and occurred due to error, the communicator should:
Consider using
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patientregistry.ahrq.gov/patient-safety/settings/hospital/candor/grand-rounds.html
August 01, 2022 - to remember what patients want in our communication with them:
An explicit statement that an error occurred … The Investigation: to determine how the event occurred, and how to mitigate that event or even prevent … This is a cornerstone of the CANDOR process of investigating the root cause of how an error occurred, … disclosure is a process , and the first step is to:
Let the patient and family know an adverse event occurred … a result of the investigation and analysis of Michelle’s case, the following patient safety changes occurred
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patientregistry.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes1.html
August 01, 2022 - understand what a CANDOR event is and what to do when they recognize that a CANDOR event is occurring or has occurred … Do:
Activity: List de-identified events that have occurred in your organization. … Once activated, the CANDOR Response Team will work with the caregivers where the event occurred to ensure
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patientregistry.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallpxreports-ig.pdf
November 09, 2017 - The new contributing risk
factor elements represent changes that occurred in a resident’s
clinical … It displays the number of falls that occurred and the
risk factors associated with the falls. … For each of the months (1 or 3)
included in the report, any fall that occurred before the report
date … For each of
the months (1 or 3) included in the report, any fall that occurred
before the report date … ,
Shift during which the fall occurred,
Time at which the fall occurred,
The location of
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patientregistry.ahrq.gov/patient-safety/settings/hospital/candor/modules/checklist5.html
August 01, 2022 - 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.
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patientregistry.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/grand-rounds-presentation-slides.pptx
January 01, 2014 - to remember what patients want in our communication with them:
An explicit statement that an error occurred … The Investigation: to determine how the event occurred, and how to mitigate that event or even prevent … This is a cornerstone of the CANDOR process of investigating the root cause of how an error occurred, … “Don’t tell me you were sorry that the problem occurred. … disclosure is a process, and the first step is to:
Let the patient and family know an adverse event occurred
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patientregistry.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module5/module5_fall-prevention.docx
June 30, 2017 - When the fall occurred.
What the degree of injury was, if any. … First, count the number of falls that occurred during the month from your incident reporting system. … Try to understand why the fall occurred and how such an incident might be prevented in the future. … individual data points are plotted and then connected (as shown by the blue line) to show that they occurred … However, it also shows a breakdown of the fall rate by the different types of falls that occurred—anticipated
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patientregistry.ahrq.gov/sites/default/files/wysiwyg/topics/fed-IWG-dxsafety-Nov19mtg.pdf
November 15, 2019 - Workgroup Summary: The latest workgroup meeting occurred virtually on November 15,
2019, from 10 a.m
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patientregistry.ahrq.gov/news/newsroom/case-studies/criteria.html
December 01, 2019 - Impact or results must have already occurred.
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patientregistry.ahrq.gov/sites/default/files/wysiwyg/topics/diagnostic-safety-workgroup-march-2022-meeting-notes.pdf
January 01, 2022 - Workgroup Summary: The latest Workgroup meeting occurred virtually on March 11, 2022,
from 11 a.m.
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patientregistry.ahrq.gov/sites/default/files/wysiwyg/topics/public-notes-meeting-summary-111921.pdf
March 11, 2022 - Workgroup Summary: The latest Workgroup meeting occurred virtually on November 19,
2021, from 1 p.m.
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patientregistry.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-5/guide.html
September 01, 2017 - When the fall occurred.
What the degree of injury was, if any. … First, count the number of falls that occurred during the month from your incident reporting system. … Try to understand why the fall occurred and how such an incident might be prevented in the future. … individual data points are plotted and then connected (as shown by the blue line) to show that they occurred … However, it also shows a breakdown of the fall rate by the different types of falls that occurred—anticipated