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www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu3a.htmlOctober 01, 2014 - Preventing Pressure Ulcers in Hospitals 3. What Are the Best Practices in Pressure Ulcer Prevention that We Want to Use? (continued) Previous Page Next Page Table of Contents Preventing Pressure Ulcers in Hospitals Overview Key Subject Area Index 1. Are we ready for this change? 2. How will …
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www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu7a.htmlAugust 01, 2017 - Preventing Pressure Ulcers in Hospitals Section 7. Tools and Resources (continued) Previous Page Next Page Table of Contents Preventing Pressure Ulcers in Hospitals Overview Key Subject Area Index 1. Are we ready for this change? 2. How will we manage change? 3. What are the best practices…
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www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu4a.htmlOctober 01, 2014 - Action Steps Choose appropriate settings for staff education about best practices in pressure ulcer
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/apc.htmlAugust 01, 2022 - Gap Analysis Facilitator's Guide: Appendix C Gap Analysis Structured Interview Guide To produce more consistently useful results, use structured interview questions. The facilitator should review the questions in advance to determine which questions are appropriate for each focus group session. It may help to…
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/apa.htmlAugust 01, 2022 - Gap Analysis Facilitator's Guide: Appendix A CANDOR Gap Analysis Document Review Checklist Instructions: At least 1 month prior to the onsite gap analysis, collect and provide the following documents for analysis by the Gap Analysis Team. Documents for Submission to Reviewers Is the document availab…
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apa.htmlAugust 01, 2022 - Event Investigation and Analysis Guide: Appendix A Five Whys In this example, there is only one path shown, but answers can create multiple paths and more questions. Event Summary: The wrong concentration of potassium (K+) was used in the compounding of TPN. This was discovered almost 2 months later. 1s…
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/ape.htmlAugust 01, 2022 - Gap Analysis Facilitator's Guide: Appendix E Gap Analysis Report Template The purpose of the Gap Analysis report is to call attention to common themes among the groups, as well as variations among the groups in their perceptions and degree of commitment to CANDOR principles. Findings should be used for target…
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/apd.htmlAugust 01, 2022 - Gap Analysis Facilitator's Guide: Appendix D Anonymous Reporting Tool The Gap Analysis process relies heavily on key informant interviews and perspectives, which often take place in a focus group setting. Many times individuals have additional, more sensitive information to share, or information/observations …
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apd.htmlAugust 01, 2022 - Event Investigation and Analysis Guide: Appendix D CANDOR Tool PROCESS QUESTIONS TO REVIEW Y/N CONTRIBUTING OR CAUSAL FACTOR Y/N FINDINGS / COMMENTS COMMUNICATION Did all caregivers have access to all pertinent information needed to make the best decisions for the patient? (e.g.,…
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apb.htmlAugust 01, 2022 - Event Investigation and Analysis Guide: Appendix B Detailed Review Timeline Event Type: Individuals Interviewed: NAME TITLE/ROLE Nurse #1 Charge nurse Nurse #2 RN CNA X Nursing tech Manager MS Manager Pertinent Interview Findings There was only one certifi…
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apc.htmlAugust 01, 2022 - Event Investigation and Analysis Guide: Appendix C Visual Model The model above is one major output from the in-depth review findings. This format helps to utilize the information found in the investigation to understand why the event occurred. The boxes represent different categories of contributing factor…
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/ape.htmlAugust 01, 2022 - Event Investigation and Analysis Guide: Appendix E Confirmation and Consensus Meeting Announcement Template As you may know, a patient care incident occurred on (insert date) involving (brief description of event). On behalf of (insert executive sponsor name), we are asking you to participate in our upcoming …
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apf.htmlAugust 01, 2022 - Event Investigation and Analysis Guide: Appendix F Solutions Meeting Announcement Template On behalf of (insert executive sponsor name), we would like you to participate in our upcoming solutions meeting related to (describe safety event). The solutions meeting will take place at (time) (date) (location). …
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apg.htmlAugust 01, 2022 - Event Investigation and Analysis Guide: Appendix G Data Measurement Plan Contributing Factor Definition / Description Current State Goal State Data Source How will data be collected? Who will collect the data? Proposed dates for measure- ment Long-term followup plan Notes Bottles…
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/api.htmlAugust 01, 2022 - Event Investigation and Analysis Guide: Appendix I Glossary Adverse safety event: a deviation from generally accepted performance standards that reaches the patient and results in moderate to severe harm or death. Anchoring bias: the tendency to make all information fit into a preconceived story, causing…
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/aph.htmlAugust 01, 2022 - Event Investigation and Analysis Guide: Appendix H Hierarchy of Solutions Do solutions meet the following criteria: Address the root cause/contributing factor. Are specific and concrete. Can be understood and implemented by a reader unfamiliar with the situation. Will be tested or simulated prior to…
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/pressureulcer.htmlDecember 01, 2017 - Pressure Ulcers Long-term care resources about pressure ulcers AHRQ's Safety Program for Nursing Homes: On-Time Prevention AHRQ's Safety Program for Nursing Homes: On-Time Prevention is funded by AHRQ, generally in collaboration with a State Department of Health, a Quality Improvement Organization (QIO), or …
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www.ahrq.gov/patient-safety/settings/hospital/red/toolkit/ahcp-components.htmlMarch 01, 2013 - Re-Engineered Discharge (RED) Toolkit Tool 3 Continued Previous Page Next Page Table of Contents Re-Engineered Discharge (RED) Toolkit Tool 1: Overview Tool 2: How To Begin the Re-engineered Discharge Implementation at Your Hospital How CMS Measures the "30-Day All Cause Rehospitalization Rate…
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www.ahrq.gov/patient-safety/settings/hospital/red/toolkit/redtool-other.htmlMarch 01, 2013 - Re-Engineered Discharge (RED) Toolkit Tool 6 (continued) Previous Page Table of Contents Re-Engineered Discharge (RED) Toolkit Tool 1: Overview Tool 2: How To Begin the Re-engineered Discharge Implementation at Your Hospital How CMS Measures the "30-Day All Cause Rehospitalization Rate" on t…
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www.ahrq.gov/patient-safety/settings/hospital/resource/qitool/webinar080116/index.htmlDecember 01, 2017 - Toolkit for Using the AHRQ Quality Indicators - A “How to” Guide for Improving Hospital Quality and Safety Slide presentation of the webinar held on August 1, 2016 The Agency for Healthcare Research and Quality (AHRQ) held a Webinar on August 1, 2016, to provide an overview of the AHRQ Quality Indicators (QIs…
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