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Showing results for "occur".

101. Learn-From-Defects-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.docx
     May 01, 2017 - The Learn From Defects Form, which provides a standardized means to assess where defects occur and to … These conditions are the mistakes that occur without human error. … Organizational failures occur when decisional elements, such as culture, procedures, and leadership decisions … By doing this, teams are able to assign meaning to the system breakdowns that occur on their L&D unit … defects on the L&D unit, it is important for staff to understand where and how breakdowns in safety occur

102. Selected Best Practices and Suggestions for Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d4c_pdi03-foreignbody-bestpractices.pdf
     November 01, 2012 - foreign objects can include perforation of the bowel, sepsis, and even death.1 These complications can occur … o A manual inspection of the incision site should occur, along with inspection of the surrounding surgical … Education should occur upon hire, annually, and when this protocol is added to job responsibilities.5 … performing a failure mode and effects analysis to better understand the process and where breakdowns can occur

103. Selected Best Practices and Suggestions for Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4b_combo_psi05-foreignbody-bestpractices.pdf
     November 01, 2012 - foreign objects can include perforation of the bowel, sepsis, and even death.1 These complications can occur … o A manual inspection of the incision site should occur, along with inspection of the surrounding surgical … Education should occur upon hire, annually, and when this protocol is added to job responsibilities.2 … performing a failure mode and effects analysis to better understand the process and where breakdowns occur

104. Selected Best Practices and Suggestions for Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4q_combo_pdi03-foreignbody-bestpractices.pdf
     November 01, 2012 - foreign objects can include perforation of the bowel, sepsis, and even death.1 These complications can occur … o A manual inspection of the incision site should occur, along with inspection of the surrounding surgical … Education should occur upon hire, annually, and when this protocol is added to job responsibilities.5 … performing a failure mode and effects analysis to better understand the process and where breakdowns can occur

105. Preface | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/advances/preface.html
     July 01, 2022 - galvanized action to reduce medical errors, there was already an emerging body of knowledge on why errors occur

106. NICU Family Information Packet, Appendix B, Nephrocalcinosis (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-nephro.pdf
     June 02, 2025 - ■ UTI and urolithiasis do not occur any more frequently than in general population.

107. Guide Promotional Postcard (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/pfeprimarycare-infographic.pdf
     April 01, 2018 - admissions are related to an adverse drug event An estimated 160 million medication errors occur

108. Final Progress Report: Evaluation of Risk by Active Surveillance in the Emergency Department (ERASED) (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/hall1-report.pdf
     January 01, 2024 - Active surveillance aids in the detection and description of a wide range of errors as they occur. … is a systematic, proactive method of process evaluation that identifies where and how failures may occur … reporting methods, and FMEA to identify, characterize, and categorize errors, both active and latent, that occur … in this project was to identify and quantify, using active surveillance, nonideal care events that occur … In other words, in an ED, it is possible that evaluation, diagnostics, and treatment may occur interlaced

109. Tool 1: Readmission Data Analysis and Interpretation (xls file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/mcaidread_tool1_data_analysis_final.xlsx
     June 02, 2025 - Topic 2: Readmissions by Payer How many readmissions occur at your hospital every year? … What you are looking for: Typically, 25% of readmissions occur within 4 days and 50% of readmissions … occur within 10 days of discharge. … How many readmissions occur at your hospital every year? … occur within 10 days of discharge.

110. Readmissions for Selected Infections Due to Medical Care: Expanding the Definition of a Patient Safety Indicator (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Gallagher2.pdf
     January 01, 2016 - • Area-level indicators identify all cases of the potentially preventable complications that occur … AHRQ developed the hospital-level PSIs to capture inpatient events that occur during a single admission … These data help estimate the volume of those adverse events that occur in the admission during which … By attributing area-level PSI cases that occur because of inpatient care to the hospital-level PSI, … Because the intent of the hospital-level indicator is to identify cases that occur after admission,

111. Health Care Simulation to Advance Safety: AHRQ Issue Brief (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/simulation-brief.pdf
     February 01, 2015 - mistakes safely, and to learn from these mistakes while avoiding patient harms that might otherwise occur … More focused forms of feedback with the guidance of an instructor are likely to occur during a debrief … clinicians’ inquiries, they may evoke a wide range of emotional and behavioral characteristics that occur … Because of the uncertainty, complexity, and rapidly emerging conditions that occur in many health care … Given that unexpected events will occur, there are lessons to be learned regarding their anticipation

112. Pressure Ulcer Prevention Toolkit (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module4/putoolkit_module4_tools.docx
     January 01, 1995 - Friction may occur when moving a person up in bed. 43. … For persons who have incontinence, skin cleaning should occur at the time of soiling and at routine intervals … Friction may occur when moving a person up in bed. True 43. … For persons who have incontinence, skin cleaning should occur at the time of soiling and at routine intervals

113. Final Progress Report: METs: Preventing Patient Crisies; Protecting Patients in Crisis (pdf file)
     www.ahrq.gov/sites/default/files/2024-11/devita-report.pdf
     January 01, 2024 - a number of authors have now identified that important and outcome-altering patient deteriorations occur … ,xi Using such criteria, Hillman conservatively estimates that some 130,000 crisis events per year occur … In the United States, 10 times that amount could occur. … Medicine in their publication To Err is Human have estimated that up to 98,000 preventable deaths occur

114. Neonatal Intensive Care: All Condition Readmissions with Gestational Age Reported: Technical Specifications (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0207-technical-specifications.pdf
     June 02, 2025 - focus on the overall quality of care of the NICU, as some of the variation in readmission rates may occur

115. Neonatal Intensive Care: All Condition Readmissions Without Gestational Age Reported: Technical Specifications (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0208-technical-specs.pdf
     June 02, 2025 - that focus solely on the overall quality of care of the NICU; some variation in readmission rates may occur

116. Adverse Drug Events Occurring in U.S. Hospitals | Agency for Healthcare Research and Quality
     www.ahrq.gov/data/infographics/adverse-drug-events.html
     August 01, 2018 - Adverse Drug Events Occurring in U.S. Hospitals Adverse Drug Events Occurring in U.S. Hospitals (PDF, 1.5 MB) Source:   HCUP Statistical Brief #164: Characteristics of Adverse Drug Events Originating During the Hospital Stay, 2011

117. Exhibit 2.14. Major Factors that Facilitated Lean Success at Central | Agency for Healthcare Research and Quality
     www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit2-14.html
     November 01, 2014 - Including physicians and hospital department leadership on the team ensured that change could occur and

118. Sensemaking and Learn from Defects for Perinatal Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.pdf
     May 01, 2017 - Defects 2 • The Learn From Defects Form, which provides a standardized means to assess where defects occur … These conditions are the mistakes that occur without human error. … • Organizational failures occur when decisional elements, such as culture, procedures, and leadership … By doing this, teams are able to assign meaning to the system breakdowns that occur on their L&D unit … defects on the L&D unit, it is important for staff to understand where and how breakdowns in safety occur

119. CAHPS Cancer Care Supplemental Items (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/cancer/suppl-items-cancer-access-english-557-1a.docx
     June 02, 2025 - Please note: Some items cover events that occur with low frequency in the general population.

120. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/factraining.html
     September 01, 2017 - Communicate risk changes as they occur. … Improve root cause analyses when adverse events occur. … When will the meeting occur? … How will communication occur with other disciplines to confirm changes in care? … When will the meeting occur?