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www.ahrq.gov/cpi/about/otherwebsites/qsrs.ahrq.gov/index.htmlMarch 01, 2021 - AHRQ Quality and Safety Review System (QSRS) Mission AHRQ has developed and tested an improved patient safety surveillance system to replace the Medicare Patient Safety Monitoring System (MPSMS). The new system is known as the Quality and Safety Review System (QSRS). The QSRS relies on clinical information re…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_7-implementation.pptxJuly 01, 2023 - other types of defect investigations Ask frontline staff Identify the process in which the challenge occurs … Identifying the process during which the problem, challenge, or opportunity occurs by stating what the … process is, who is involved, and when and where it occurs. 6 Specific Situations Facility (and unit
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_7-implementation.pptxJuly 01, 2023 - other types of defect investigations Ask frontline staff Identify the process in which the challenge occurs … Identifying the process during which the problem, challenge, or opportunity occurs by stating what the … process is, who is involved, and when and where it occurs. 6 Specific Situations Facility (and unit
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4.htmlAugust 01, 2022 - When an adverse event occurs, too often, the focus is on an individual's performance and is corrected … that the organization identify a group of individuals who can be immediately available when an event occurs
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www.ahrq.gov/sites/default/files/2024-01/shenep-report.pdfJanuary 01, 2024 - Documented and frequent; the condition occurs very regularly and or during a reasonable amount of time … Patient death occurs. Process fails. Almost certain 4 or more per 10 events.
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CHIPRA 213: Section 5, Table 4 (pdf file)
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-213-section-5-table-4.pdfJanuary 01, 2012 - If no major toxicity occurs, dose may be escalated every 6 to 8 weeks until the desired endpoints are -
www.ahrq.gov/research/findings/final-reports/crctoolkit/crctool2a-1.htmlApril 01, 2018 - Clinicians, and ALL Other Staff) This section asks about how the colorectal cancer screening process occurs
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www.ahrq.gov/hai/tools/mvp/modules/cusp/science-of-safety-fac-guide.htmlFebruary 01, 2017 - All too often we assume that patient harm occurs because of inexperience, lack of supervision, or bad
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www.ahrq.gov/sites/default/files/2024-09/weissman-report.pdfJanuary 01, 2024 - Final Progress Report: Weekend Effects and the July Phenomenon in Patient Safety --------------------------------------- Weekend Effects and the July Phenomenon in Patient Safety Final Research Report to AHRQ Principal Investigator: Joel S. Weissman, PhD February 6, 2006 Co-Investigators and Study Staff (i…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Kline_32.pdfMarch 03, 2008 - Unfortunately, when serious injury (e.g., hip fracture) occurs, surgical repair is necessary, the patient … An assisted fall occurs when a patient is being accompanied by a care provider and begins to fall, typically
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An Analysis of Nurses' Cognitive Work: A New Perspective for Understanding Medical Errors (pdf file)
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Potter.pdfJanuary 01, 2003 - An Analysis of Nurses' Cognitive Work: A New Perspective for Understanding Medical Errors 39 An Analysis of Nurses’ Cognitive Work: A New Perspective for Understanding Medical Errors Patricia Potter, Laurie Wolf, Stuart Boxerman, Deborah Grayson, Jennifer Sledge, Clay Dunagan, Bradley Evanoff Abstract He… -
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Flack.pdfJanuary 01, 2005 - medical devices so it could become more proactive in addressing device issues before a death or injury occurs … This typically occurs in organizations that have a “blaming” culture when errors occur. … of the interaction the reporters have with the MedSun contractor during the initial follow-up that occurs
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Learning-From-Antibiotic-Adverse (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/learning-from-antibiotic-adverse.docxJune 01, 2021 - AHRQ Safety Program for Improving Antibiotic Use Learning From Antibiotic-Associated Adverse Events An antibiotic-associated adverse event is any event or situation that you would not want to happen again because it either caused your patient harm or had the potential to cause harm. The purpose of this tool is to provi… -
www.ahrq.gov/practiceimprovement/delivery-initiative/ihs/chapter9.htmlDecember 01, 2017 - ARRA ACTION: Comparative Effectiveness of Health Care Delivery Systems for American Indians and Alaska Natives Using Enhanced Data Infrastructure Chapter 9. Potential Future Uses of the Data Infrastructure Previous Page Next Page Table of Contents ARRA ACTION: Comparative Effectiveness of Health Car…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/data-change-notes.docxApril 01, 2022 - · Top three strengths and weaknesses identified by unit – this is where the bulk of the discussion occurs … see, so make sure your CUSP team is actively involved in making these decisions and ensuring sharing occurs
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/3.htmlDecember 01, 2017 - AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention Functional Specifications 3. Specifications for Each Pressure Ulcer Prevention Report (continued) 3.3. Weight Summary Report 3.3.1. Report Description The Weight Summary Report displays 4 weeks of trended weight information for e…
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www.ahrq.gov/research/findings/final-reports/stpra/stpra4.htmlApril 01, 2018 - Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers Chapter 4. Conclusions and Next Steps Previous Page Next Page Table of Contents Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers Executive Summary Chapter 1. Introduction Chapte…
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www.ahrq.gov/patient-safety/reports/liability/baker.htmlAugust 01, 2017 - agreement among patients and family members regarding what should be disclosed when an adverse event occurs
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Gallagher1.pdfJanuary 01, 2004 - This occurs when a Advances in Patient Safety: Vol. 2 30 patient has a primary diagnosis of accidental … One of the primary procedures that occurs often in this PSI is hysterectomy.
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Reducing Unecessary Urinary catheter Use in the Emergency Department: How to Implement the Process (ppt file)
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/ed-catheter-insertions-091013.pptJanuary 01, 2010 - and critical application Moral agency Drive to act Environmental Context in which decision making occurs … beneficence and non-maleficence Putting systems in place Environmental: Context in which decision making occurs
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