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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/preventing/module3.docx
June 01, 2017 - FCCM, FCCP
Patient Safety & Clinical Effectiveness Officer
Director, Critical Care Medicine
Director, Palliative
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www.ahrq.gov/sites/default/files/2024-10/weinger-france-report.pdf
January 01, 2024 - response
2
December 27, 2023
CaPSLL Final Report
PURPOSE
A common cause of preventable harm … with patient-reported outcome measures
(PROMs).52 Based on evidence from highly reliable care and palliative … Patients
demonstrated comfort and confidence actively reporting PROMS (90% data capture), including … a multi-national digital intervention, is being developed and validated (n=9 patients) to
improve palliative … completed a feasibility
study (n=30 patients) of a continuous monitoring system for cancer patients in palliative
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/module3-transcript.pdf
June 01, 2017 - FCCP
Patient Safety & Clinical Effectiveness Officer
Director, Critical Care Medicine
Director, Palliative
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/medical-office/2010/moimpptsaf.pdf
January 01, 2010 - CAHPS® Improvement Guide
Change the Work Environment
Chasing Zero: Winning the War on Health Care Harm … These practices can be universally
adopted by all health care settings to reduce the risk of harm to … Chasing Zero: Winning the War on Health Care Harm
http://discoveryhealthcme.discovery.com/zero/media … aimed at providing a collective voice for individuals, families, and healers who want to
prevent harm … decrease the number of discrepant medication orders and the associated potential and actual
patient harm
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www.ahrq.gov/sites/default/files/publications2/files/MeasureDx-guide.pdf
July 01, 2022 - of harm … after date/time of hospital
discharge
Clinical Exclusion
� Deceased at discharge or code
status of comfort … Transfers for postprocedure care
� >2 prior hospitalizations in the
past year
� Transfer to hospice or palliative … Pediatric clinician comfort discussing
diagnostic errors for improving patient safety: a survey. … We want to know: patient comfort
speaking up about breakdowns in care and patient experience.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/impl-guide/implementation-guide.pdf
September 01, 2015 - errors are treated as an opportunity to learn
about root causes and prevent future errors and risks of harm … Hospice/comfort/palliative care—This is an acceptable indication for catheter use in end-
of-life care … when it facilitates meeting patient and family goals in a dying patient or helps
with patient comfort … An exception would be for patients who are receiving end-of-
life or palliative care and in whom a catheter … Frontline
staff will have daily information about how well they are doing to prevent this patient harm
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www.ahrq.gov/sites/default/files/publications/files/implementation-guide_0.pdf
September 01, 2015 - errors are treated as an opportunity to learn
about root causes and prevent future errors and risks of harm … Hospice/comfort/palliative care—This is an acceptable indication for catheter use in end-
of-life care … when it facilitates meeting patient and family goals in a dying patient or helps
with patient comfort … An exception would be for patients who are receiving end-of-
life or palliative care and in whom a catheter … Frontline
staff will have daily information about how well they are doing to prevent this patient harm
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www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2021.pdf
January 01, 2021 - No Harm, or Harm (i.e., Mild harm, Moderate harm, Severe harm or Death). … No Harm, or Harm (i.e., Mild harm, Moderate harm, Severe harm or Death). … involvement
■ A mucosal, arterial or venous ulcer
■ A diabetic foot ulcer
■ A pressure ulcer related to palliative … DVT and/or PE identified on screening exam or incidentally)
VTE occurring in a patient receiving palliative … or comfort care
Thrombosis involving another venous system such as intracranial veins or sinuses,
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/guides/resphys-champions.pdf
September 01, 2015 - Complications ............................................................... 4
Examples of Patient Harm … AHRQ Safety Program for Reducing CAUTI in Hospitals Resident Physicians 6
Examples of Patient Harm … End-of-life care (hospice/comfort/palliative care). This addresses patient comfort at
end of life. … Cultures from nonsterile sites may trigger inappropriate antimicrobial use and risk patient
harm. … ill patients, assist healing of sacral and perineal
wounds in those with incontinence, or improve comfort
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www.ahrq.gov/sites/default/files/publications/files/resphys-champions_2.pdf
September 01, 2015 - Complications ............................................................... 4
Examples of Patient Harm … AHRQ Safety Program for Reducing CAUTI in Hospitals Resident Physicians 6
Examples of Patient Harm … End-of-life care (hospice/comfort/palliative care). This addresses patient comfort at
end of life. … Cultures from nonsterile sites may trigger inappropriate antimicrobial use and risk patient
harm. … ill patients, assist healing of sacral and perineal
wounds in those with incontinence, or improve comfort
-
www.ahrq.gov/sites/default/files/publications/files/resphys-champions.pdf
September 01, 2015 - Complications ............................................................... 4
Examples of Patient Harm … AHRQ Safety Program for Reducing CAUTI in Hospitals Resident Physicians 6
Examples of Patient Harm … End-of-life care (hospice/comfort/palliative care). This addresses patient comfort at
end of life. … Cultures from nonsterile sites may trigger inappropriate antimicrobial use and risk patient
harm. … ill patients, assist healing of sacral and perineal
wounds in those with incontinence, or improve comfort
-
www.ahrq.gov/research/findings/studies/index.html?page=84
January 01, 2024 - sought to identify participant-rated items contributing to patient attitudes, beliefs, and level of comfort … found that participants expressed significant support for intraoperative telemedicine use and greater comfort … highlights the importance of patient safety and that encourages team collaboration has demonstrated that harm
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www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2020.pdf
January 01, 2020 - No Harm, or Harm (i.e., Mild harm, Moderate harm, Severe harm or Death). … No Harm, or Harm (i.e., Mild harm, Moderate harm, Severe harm or Death). … No Harm, or Harm (i.e., Mild harm, Moderate harm, Severe harm or Death). … DVT and/or PE identified on screening exam or incidentally)
VTE occurring in a patient receiving palliative … or comfort care
Thrombosis involving another venous system such as intracranial veins or sinuses,
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www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2019.pdf
January 01, 2019 - No Harm, or Harm (i.e., Mild harm, Moderate harm, Severe harm or Death). … No Harm, or Harm (i.e., Mild harm, Moderate harm, Severe harm or Death). … No Harm, or Harm (i.e., Mild harm, Moderate harm, Severe harm or Death). … DVT and/or PE identified on screening exam or incidentally)
VTE occurring in a patient receiving palliative … or comfort care
Thrombosis involving another venous system such as intracranial veins or sinuses,
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www.ahrq.gov/research/findings/studies/index.html?page=32
January 01, 2024 - , Antibiotics, Medication, Risk
Wong CI , Vannatta K , Gilleland Marchak J Preventable harm … The goal of this longitudinal study was to characterize rates and types of medication errors and harm … Preventable harm because of outpatient medication errors among children with leukemia and lymphoma: a … The researchers conclude that such patients may benefit from increased access to palliative and other … observations, all interviewees were satisfied with the TMH-V program, and interviewees emphasized greater comfort
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www.ahrq.gov/sites/default/files/2025-03/blike-report.pdf
January 01, 2025 - The sampling rates need to be such that events occurring over seconds and causing harm in minutes
can … be detected and rescue initiated before harm occurs.
6. … No patients experienced permanent harm due to sedative/
analgesic medication administration during the … All patients on the palliative care service were excluded. … a 100% inpatient review, excluding complications present on admission and
patients admitted to the palliative
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www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/research/engaging-challenging-full.pdf
May 01, 2024 - Overdiagnosis: an underrecognized cause of confusion and harm in cancer
screening. … Mammography for breast cancer screening:
harm/benefit analysis. … deadopt* OR
“de-adopt*”) OR TI (Deimplement*
OR "de-implement*" OR "Medical
Overuse" OR "Patient Harm … breast cancer screening emphasizes
harms of screening: “Mammography for Breast
Cancer Screening: Harm … System
Chief of UCSF Division of
Geriatrics and Professor of
Medicine; Section Chief,
Geriatrics, Palliative
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/healthyliving/qdr2015-chartbook-healthyliving.pptx
January 01, 2020 - Chartbooks Organized Around Priorities of the National Quality Strategy
Making care safer by reducing harm … Reducing the risk of harm from medication errors in children. … Accessed March 24, 2016.
93
Supportive and Palliative Care
Chartbook on Healthy Living
94
Goals … Supportive and palliative care:
Cuts across many medical conditions. … Focuses on enhancing patient comfort and quality of life and preventing and relieving symptoms and complications
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www.ahrq.gov/research/findings/nhqrdr/chartbooks/healthyliving/healthyliving-slides.html
April 01, 2018 - Supportive and Palliative Care. … Chartbooks Organized Around Priorities of the National Quality Strategy
Making care safer by reducing harm … Supportive and Palliative Care. … Reducing the risk of harm from medication errors in children. … Focuses on enhancing patient comfort and quality of life and preventing and relieving symptoms and complications
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/lepguide/lepguide.pdf
September 01, 2012 - Many
of the cases reviewed resulted in patients suffering death or irreparable harm. … in harm to the patient. … No
detectable
harm
Minimal
temporary
harm
Moderate
temporary
harm
Severe
temporary
harm
Severe … permanent
harm
Death
English Speaking
Limited English Proficient
Figure 3. … Types of Physical Harm Experienced From Adverse Events by English-Speaking and LEP Patients
Source: