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pcmh.ahrq.gov/patient-safety/about/challenge-competition.html
February 01, 2024 - The most visible advances occurred in the services and nursing units (a 50% reduction in general surgery
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/grandrounds/mod01-grand-rounds-slides.pdf
April 01, 2016 - An explicit statement that an error occurred.
2. … 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 … result of the investigation and analysis of Michelle’s case, the following
patient safety changes occurred
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pcmh.ahrq.gov/hai/cusp/toolkit/index.html
July 01, 2018 - the Nationwide Implementation of the Comprehensive Unit-based Safety Program (CUSP)
These webinars occurred
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pcmh.ahrq.gov/teamstepps-program/curriculum/team/tools/debrief.html
December 01, 2023 - Analysis of why the event occurred, what worked, and what did not work.
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pcmh.ahrq.gov/teamstepps-program/curriculum/mutual/overview/index.html
July 01, 2023 - Timely— given soon after the target behavior has occurred.
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pcmh.ahrq.gov/teamstepps/instructor/scenarios/dental.html
March 01, 2014 - In this scenario, either of two actions should have occurred. … Had a brief or check-back occurred, they would have shared their individual situation awareness with
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pcmh.ahrq.gov/news/newsroom/case-studies/201801.html
April 01, 2018 - The majority of falls occurred as patients left their beds to walk to or from the bathrooms, Myers said
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pcmh.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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pcmh.ahrq.gov/news/newsroom/case-studies/ktcquips91.html
October 01, 2014 - responsibility for completing medication reconciliation to the ICU charge nurse to eliminate the confusion that occurred
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pcmh.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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pcmh.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
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pcmh.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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pcmh.ahrq.gov/page/medical-home-what-do-we-know-what-do-we-need-know-review-earliest-evidence-effectiveness-of-the-patient-centered-medical-home-model-table-4-1
March 01, 2013 - baseline differences in the outcomes Low: 1 of 19 process of care measures (followup primary care visit occurred
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pcmh.ahrq.gov/page/early-evidence-patient-centered-medical-home-table-31
February 01, 2012 - differences in the outcomes
Low: 1 of 19 process of care measures (followup primary care visit occurred
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pcmh.ahrq.gov/talkingquality/translate/labels/describe.html
January 01, 2023 - would almost always be placed by a doctor, so the nurse should not be held accountable if an infection occurred
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pcmh.ahrq.gov/news/newsletters/e-newsletter/index.html
April 30, 2024 - of Digital Healthcare Technologies Advance Equity
April 9, 2024
Surge in Drug Shortages Occurred
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pcmh.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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pcmh.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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pcmh.ahrq.gov/sites/default/files/publications/files/hacrate2013_0.pdf
October 01, 2015 - hospital patients over the 3 years (2011, 2012, 2013) 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 … Costs included the initial hospital stay and costs of other inpatient sites
of care that occurred within … in
2013 than would have occurred if the rate of HACs had remained steady at the 2010 level
(Exhibit … The majority of deaths averted occurred as a
result of reductions in the rates of pressure ulcers
14
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pcmh.ahrq.gov/cahps/surveys-guidance/hospital/about/adult_hp_survey.html
November 01, 2023 - CMS implemented the HCAHPS survey in October 2006, and the first public reporting of HCAHPS results occurred