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Total Results: 4,075 records

Showing results for "happened".

  1. Incorporating Patient Preferences in Patient-Centered Clinical Decision Support (pdf file)

    cdsic.ahrq.gov/sites/default/files/2025-06/TPC%20Topic%20Highlight%20Patient%20Preferences.pdf
    January 01, 2025 - Incorporating Patient Preferences in Patient-Centered Clinical Decision Support AHRQ Pub. No. 25-0055 June 2025 Incorporating Patient Preferences in Patient-Centered Clinical Decision Support Patient preferences can support a patient’s care experience and healthcare decision making. This resource shows differe…

  2. Discharge Fumbles | PSNet

    psnet.ahrq.gov/web-mm/discharge-fumbles
    September 09, 2009 - SPOTLIGHT CASE Discharge Fumbles Citation Text: Forster AJ. Discharge Fumbles. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…

  3. When the Indications for Drug Administration Blur | PSNet

    psnet.ahrq.gov/web-mm/when-indications-drug-administration-blur
    May 26, 2021 - SPOTLIGHT CASE When the Indications for Drug Administration Blur Citation Text: Munsch J, Doroy A. When the Indications for Drug Administration Blur . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation …

  4. The Inside of a Time Out | PSNet

    psnet.ahrq.gov/web-mm/inside-time-out
    March 01, 2004 - The Inside of a Time Out Citation Text: Feldman DL. The Inside of a Time Out. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged …

  5. Impact of Staff-Led Safety Walk Rounds (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Montgomery_42.pdf
    March 05, 2008 - Impact of Staff-Led Safety Walk Rounds Impact of Staff-Led Safety Walk Rounds Vicki L. Montgomery, MD, FAAP, FCCM Abstract Objectives: The primary objectives of this study were to provide a venue for discussing safety concerns and to facilitate finding solutions for everyday safety issues. Methods: The mul…

  6. Transitional Care Medication Safety: Stakeholders' Perspectives | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/reports/liability/corbett.html
    August 01, 2017 - Whatever happened to qualitative description? Res Nurs Health 2000; 23:334-40. 25.

  7. Development and Validation of the Medication Administration Error Reporting Survey (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Wakefield2.pdf
    January 01, 2003 - First, by definition, recognition that an error has occurred means that the error happened some time

  8. In Conversation With... James Augustine, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-james-augustine-md
    July 28, 2021 - And I happened to be reviewing one of those today, so it's fresh in my mind. … A patient had some symptoms and then didn't, and then had symptoms again, and when the EMS group happened

  9. Creating Safety in the Testing Process in Primary Care Offices (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Elder_18.pdf
    February 19, 2008 - of the general process flow than were the MAs, physicians, or clerical staff, who rarely knew what happened … For example, at one office, a physician, when asked what happened to test results that came back when

  10. Improving Communication and Teamwork in the Surgical Environment

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/training-tools/training-tools-slideset.pptx
    May 01, 2017 - What happened to the system as we improved the outcome and process measures?

  11. In Conversation With…David C. Classen, MD, MS | PSNet

    psnet.ahrq.gov/perspective/conversation-withdavid-c-classen-md-ms
    May 01, 2012 - I take the long-term view that if you look at what happened in the airlines, it took them decades to

  12. Strategy 3: Nurse Bedside Shift Report Implementation Handbook (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy3/Strat3_Implement_Hndbook_508.docx
    August 01, 2010 - What happened during training that could challenge or facilitate implementation?

  13. The Emergence of the Trigger Tool as the Premier Measurement Strategy for Patient Safety | PSNet

    psnet.ahrq.gov/perspective/emergence-trigger-tool-premier-measurement-strategy-patient-safety
    May 01, 2012 - I take the long-term view that if you look at what happened in the airlines, it took them decades to

  14. Disposition of Comments for Technical Brief 25 Disparities within Serious Mental Illness (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/mental-illness-disparities_disposition-comments.pdf
    May 26, 2016 - Rather, as it happened, each of the studies that were identified as eligible happened to involve PTSD

  15. Learning from Errors in Ambulatory Pediatrics (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Mohr.pdf
    February 01, 2004 - focus group session, many pediatricians acknowledged that errors with the potential to harm patients happened … reporting period], I was going up to people, saying ‘let me tell you about an error I made—has this ever happened

  16. Final Progress Report: The National Quality Forum Fall Policy Conference 2008 (pdf file)

    www.ahrq.gov/sites/default/files/2025-02/mcneil-report.pdf
    January 01, 2025 - Final Progress Report: The National Quality Forum Fall Policy Conference 2008 The National Quality Forum Fall Policy Conference 2008 Principal Investigator: Dwight McNeil Team Members: S. Callahan, L. Gorban, D. McNeill, and B. Yelin 9/30/08-9/29/09 Federal Project Official: Karen Ho Supported by: Agen…

  17. Facilitator Guide: Implementing Your SSI Prevention Bundle (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_ssibundle_facnotes.docx
    December 01, 2017 - Facilitator Guide: Implementing Your SSI Prevention Bundle Slide Title and Commentary Slide Number and Slide Implementing Your SSI Prevention Bundle SAY: This module is about implementing your surgical site infection (SSI) prevention bundle. Slide 1 Learning Objectives SAY: This module will help you develop …

  18. Implementing Your Surgical Site Infection Prevention Bundle: Facilitator Notes | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/tools/surgery/modules/implementation/ssi-bundle-fac-notes.html
    October 01, 2020 - Implementing Your Surgical Site Infection Prevention Bundle: Facilitator Notes AHRQ Safety Program for Surgery Slide 1: Implementing Your SSI Prevention Bundle Say: This module is about implementing your surgical site infection (SSI) prevention bundle. Slide 2: Learning Objectives Say: This modu…

  19. Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected | PSNet

    psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect-unexpected
    September 25, 2024 - root cause analysis, interviews, and human and environmental factor analysis are used to examine what happened

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867357/psn-pdf
    December 18, 2024 - Lack of gas supply, as happened in this case, is a major cause of ventilator malfunction.
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