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Showing results for "occur".

161. Facilitator-Notes (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module4/facilitator-notes.docx
     March 01, 2017 - SLIDE 16 SAY: Handoffs occur during a change in assignment for the responsibility of caring for a … A handoff may occur when a resident is first welcomed to the nursing home from the hospital or during … another staff member, even for a short timespan such as a lunch break, a structured communication should occur

162. Module I: Does the Innovation Fit? | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/innovations/will-work/guide1.html
     February 01, 2021 - When and where does the problem occur? What causes the problem? … How frequently does the problem occur? What is the severity of the problem? … For example, mismatches may occur when an organization: Encourages experimentation and ad hoc problem

163. Chapter 1: Background on Patient Safety and LEP Populations | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/health-literacy/professional-training/lepguide/chapter1.html
     September 01, 2020 - Medical errors can occur anywhere in the health care system: hospitals, clinics, outpatient surgery centers … event" refers to a particularly shocking medical error (such as wrong-site surgery) that should never occur … LEP patients are more likely than English-speaking patients to suffer from physical harm when errors occur … situations, which we call high-risk scenarios, where adverse events and medical errors are most likely to occur … 6 shows examples from actual patient safety reports that illustrate the delays and errors that can occur

164. Cusp Patient Family Engagement Facilitator Notes (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/patfamilyengagement/CUSP_Patient_Family_Engagement_Facilitator_Notes.docx
     September 13, 2013 - consider: · Planning and design · Everyday care · After an adverse event Slide 21 SAY: Adverse events occur … Rarely does an adverse event occur as a result of intent.

165. Communication-Facilitator-Guide (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/communication-facilitator-guide.docx
     June 01, 2021 - This can occur after someone has had antibiotics and can be devastating in nursing home residents. … 13 Case 3: Communication SAY: Let’s walk through a final case of communication errors that can occur … The nurse does not feel comfortable with this plan and knows that serious side effects can occur on antibiotics … Slide 16 Case 3 — DESC Script SAY: Conflict can occur in teams, and it is important to know how … to handle such situations when they occur.

166. 5. How do you measure fall rates and fall prevention practices? | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/measure-fall-rates.html
     January 01, 2013 - Sometimes staff would like to simply track the number of falls that occur every month or every quarter … An individual-level root cause analysis can occur after any fall, particularly falls with injury. … For more information on the public reporting of falls with trauma that occur in hospitals participating

167. Risk-Based Patient Safety Metrics (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Scanlon_62.pdf
     March 25, 2008 - If an error rate is: Identified errors Potential opportunities for that error to occur then, the … In order for chart review to identify all errors, the following sequence of events must occur: Error … The need for each of these additional steps to occur perfectly makes it less likely that chart review … That rate would be: Identified injuries Potential opportunities for those injuries to occur As … Thus, the error might occur and go undiscovered and unmeasured.

168. Using Probabilistic Risk Assessment to Model Medication System Failures in Long-term Care Facilities (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Comden.pdf
     January 01, 2003 - drug, wrong-dose, omitted-dose/drug, and wrong-patient medication errors) were modeled because they occur … wrong dose on order Q:0.001 Gate363 Read back occurs and fails Q:0.28 Event593 Read back does not occur … wrong dose on order Q:0.001 Gate363 Read back occurs and fails Q:0.28 Event593 Read back does not occur … These practices are generally forbidden in P&Ps, but this study found that they occur with some frequency … Too often, when adverse events occur, health care professionals lack the time and/or resources to thoroughly

169. Medication Discrepancies and Potential Adverse Drug Events During Transfer of Care from Hospital to Home | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/reports/liability/neumiller.html
     August 01, 2017 - Preventable adverse drug events (ADEs) have been shown to frequently occur in a variety of settings, … at least one medication discrepancy in the transition from hospital to home care, and discrepancies occur … costs were estimated to exceed $117 billion. 28 ADEs that are primarily the result of human errors occur … As discussed previously, preventable ADEs have been shown to occur frequently in a variety of settings … Conclusion Medication discrepancies frequently occur during the transition from hospital to home care

170. Choosing a Stewardship Intervention and Measuring Change (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/intervention-worksheet.pdf
     June 01, 2021 - Choosing a Stewardship Intervention and Measuring Change • Antibiotic stewardship interventions can occur

171. Supplemental-Healthpromotion-Education-Cgcahps-Adult-2357-11A (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/item-sets/CG/supplemental-healthpromotion-education-cgcahps-adult-2357-11a.docx
     September 21, 2017 - Some items cover events that occur with low frequency in the general population.

172. Suppl Pcmh-Items Cg-Cahps-Adult-Survey 2357-2A (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/cg/instructions/suppl_pcmh-items_cg-cahps-adult-survey_2357-2a.docx
     March 11, 2016 - Some items cover events that occur with low frequency in the general population.

173. CAHPS Cancer Care Supplemental Items (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/cancer/suppl-items-cancer-info-english-557-6a.docx
     March 07, 2017 - Please note: Some items cover events that occur with low frequency in the general population.

174. PPE
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/educational-bundles/infection-prevention/precautions/ppe-precautions.pptx
     March 01, 2017 - performed; the anticipated degree of contact with blood and/or body fluids or pathogen exposure that might occur … during that task; and whether or not splashing or sprays may occur.1 Once these three elements are … Contamination can occur through direct contact with blood or body fluids, mucous membranes, nonintact

175. PowerPoint Presentation
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module7/module7-resolution-facilitator.pptx
     August 24, 2015 - resolution process before and after CANDOR implementation. 2 Module 7 When adverse patient events occur

176. Engage Patients and Families for Perinatal Safety (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/pf-engagement-facilitator-guide.pdf
     May 01, 2017 - Slide 16 SAY: Adverse events occur when a patient is harmed as a result of receiving medical care … Rarely does an adverse event occur as a result of intent.

177. The Contribution of Diagnostic Error to Maternal Mortality and Severe Maternal Morbidity | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/maternal-mortality-2.html
     September 01, 2021 - Communication breakdowns can occur between patients and providers and within the healthcare team in an

178. Reducing Workplace Violence with TeamSTEPPS® | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/teamstepps/events/webinars/dec-2016.html
     July 01, 2018 - Communication and Teamwork Slide 13: No Slide Title Slide 14: Team Structure Slide 15: Where May Violence Occur … Return to Contents   Slide 15 Where May Violence Occur? … Violence may occur anywhere in the health care facility, but it is most frequent in the following areas

179. How To Implement the Pressure Injury Prevention Program in Your Organization
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module4/module4_pu-implementation_slides.pptx
     November 20, 2014 - Unit staff tell the Wound Care Team about high-risk patients or if skin problems occur. … 19 Practice Insight Staff Turnover 20 Communication Patterns Good communication needs to occur

180. Selected Best Practices and Suggestions for Improvement (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4m_combo_psi18-19-obstetriclaceration-bestpractices.pdf
     May 20, 2016 - • The rate of third or fourth degree perineal lacerations range from 4% to 13%.1 • When they do occur … Education should occur upon hire, annually, and when this protocol is added to job responsibilities.2