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Showing results for "happened".

1941. Learning from AHRQ's Diagnostic Safety Culture Survey at a Tertiary Care Health System in Brazil: A Case Study (pdf file)
      www.ahrq.gov/sites/default/files/publications2/files/dx-issue-brief-20-brazil-health-system.pdf
      August 01, 2024 - and the second related to whether the office was informed when a missed, wrong, or delayed diagnosis happened

1942. Develop and Validate Health IT Safety Measures To Capture Violations of the Five Rights of Medication Safety | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/develop-and-validate-health-it-safety-measures-capture-violations-five-rights
      January 01, 2023 - events every 30 minutes and then contact clinicians within 6 hours of each RAR event to understand what happened

1943. Communication Error in a Closed ICU | PSNet
      psnet.ahrq.gov/web-mm/communication-error-closed-icu
      July 01, 2016 - Rather than working together to understand how such an error could have happened, the ICU team and the

1944. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39923/psn-pdf
      September 03, 2014 - Sued for misdiagnosis? It could happen to you. September 3, 2014 Lippman H, Davenport J. Sued for misdiagnosis? It could happen to you. J Fam Pract. 2010;59(9):498-508. https://psnet.ahrq.gov/issue/sued-misdiagnosis-it-could-happen-you This article explains how to avoid diagnostic error, minimize litigation, and pr…

1945. Research on Person-Centered Care
      www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/webinars/ncepcr-webinar-person-centered-care.pptx
      June 27, 2024 - by involving the patient in weighing the pre-determined options for a pre-specified problem SDM happened … Improvement Strategy Priorities 52 Top care improvement objectives selected from 27 total And look what happened

1946. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40194/psn-pdf
      June 20, 2011 - What happens when things go wrong? June 20, 2011 Brandom BW, Callahan P, Micalizzi DA. What happens when things go wrong? Paediatr Anaesth. 2011;21(7):730-6. doi:10.1111/j.1460-9592.2010.03513.x. https://psnet.ahrq.gov/issue/what-happens-when-things-go-wrong This commentary reveals a personal story of loss and dis…

1947. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38215/psn-pdf
      November 14, 2011 - Could it happen here? Learning from other organizations' safety errors. November 14, 2011 Conway JB. Could it happen here? Learning from other organizations' safety errors. Healthcare Executive. 2008;23(6):64, 66-67. https://psnet.ahrq.gov/issue/could-it-happen-here-learning-other-organizations-safety-errors This…

1948. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33839/psn-pdf
      August 01, 2017 - Then let's talk about what happened in terms of its impact on policy.

1949. Primary Care Practice Facilitation Curriculum Module 8: Approaches to Quality Improvement (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-8-approaches-to-qi.pdf
      September 01, 2015 - the test is carried Measures to determine if prediction succeeds out Do Describe what actually happened

1950. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33744/psn-pdf
      February 01, 2013 - , their thoughts about the transition to home, their concerns about safety, their views about what happened

1951. The Case of Mistaken Intubation | PSNet
      psnet.ahrq.gov/web-mm/case-mistaken-intubation
      July 01, 2016 - The inpatient team happened to be the same team that had recently discharged him.

1952. AHRQ Slide Template 2004 (ppt file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruprev/spectorhudak.ppt
      December 01, 2013 - AHRQ Slide Template 2004 On-Time Prevention Program for Long Term Care: Clinical Decision Support William Spector, Ph.D. AHRQ Sandra Hudak, MS RN SLH Clinical Consulting Presentation at AHIMA June 17, 2013 Baltimore, MD Using HIT for Prevention in Nursing Homes Pressure ulcers, falls, and preventable hospitali…

1953. Appendix K. CAUTI Case Review Form | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/resources/tools/cauti-surveillance/review-form.html
      March 01, 2017 - Appendix K. CAUTI Case Review Form AHRQ Safety Program for Long-Term Care: HAIs/CAUTI Purpose The CAUTI Case Review Form is a performance improvement look-back tool that assists long-term care (LTC) facilities with identifying possible resident care issues that might have contributed to a cathet…

1954. SOPS® Diagnostic Safety Supplemental Item Set for the SOPS Medical Office Survey (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/Final-DX-Safety-items-12-15-2022.docx
      January 01, 2022 - SOPS® Diagnostic Safety Supplemental Item Set for the SOPS Medical Office Survey SOPS® Diagnostic Safety Supplemental Item Set for the SOPS Medical Office Survey Language: English Purpose: This supplemental item set was designed for use with the core SOPS® Medical Office Survey to help medical offices assess the exte…

1955. SOPS® Diagnostic Safety Supplemental Item Set for the SOPS Medical Office Survey (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/Final-DX-Safety-items-2022-1215-ENGLISH-508.pdf
      January 01, 2022 - SOPS® Diagnostic Safety Supplemental Item Set for the SOPS Medical Office Survey 1 SOPS® Diagnostic Safety Supplemental Item Set for the SOPS Medical Office Survey Language: English Purpose: This supplemental item set was designed for use with the core SOPS® Medical Office Survey to help medical offices asse…

1956. Workflow (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/workflow-analysis-qi.pdf
      February 01, 2005 - Workflow Workflow Ann Lefebvre MSW, CPHQ Associate Director, NC AHEC North Carolina Area Health Education Centers North Carolina Area Health Education Centers “Every system is perfectly designed to get the results that it gets.” Paul Batalden, MD North Carolina Area Health Education CentersNorth Carolina…

1957. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39489/psn-pdf
      June 11, 2010 - What happens between visits? Adverse and potential adverse events among a low-income, urban, ambulatory population with diabetes. June 11, 2010 Sarkar U, Handley MA, Gupta R, et al. What happens between visits? Adverse and potential adverse events among a low-income, urban, ambulatory population with diabetes. Qua…

1958. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35181/psn-pdf
      June 23, 2009 - Communication during trauma resuscitation: do we know what is happening? June 23, 2009 Bergs EAG, Rutten FLPA, Tadros T, et al. Communication during trauma resuscitation: do we know what is happening? Injury. 2005;36(8):905-11. https://psnet.ahrq.gov/issue/communication-during-trauma-resuscitation-do-we-know-what-…

1959. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44359/psn-pdf
      January 06, 2016 - What happens when healthcare innovations collide? January 6, 2016 Pendharkar SR, Woiceshyn J, da Silveira GJC, et al. What happens when healthcare innovations collide? BMJ Qual Saf. 2016;25(1):9-13. doi:10.1136/bmjqs-2015-004441. https://psnet.ahrq.gov/issue/what-happens-when-healthcare-innovations-collide Innovat…

1960. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44132/psn-pdf
      May 13, 2015 - Adverse outcomes: why bad things happen to good people. May 13, 2015 Sonnenberg A. Adverse outcomes: why bad things happen to good people. Clin Gastroenterol Hepatol. 2015;13(5):820-3.e1. doi:10.1016/j.cgh.2014.07.064. https://psnet.ahrq.gov/issue/adverse-outcomes-why-bad-things-happen-good-people This commentary…