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Total Results: 4,281 records

Showing results for "occur".

161. Sensemakingnotes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/identify/sensemakingnotes.docx
     August 08, 2012 - . · The Learn from Defects Form, which provides a standardized means to assess where defects occur and … in that the failure mode and effects analysis searches for all possible ways in which an event could occur … These conditions are the mistakes that occur without human error. … failures are problems with physical items, such as equipment and software. · Organizational failures occur … By doing this, teams are able to assign meaning to the system breakdowns that occur on their units.

162. Supplemental Items for the CAHPS Clinician & Group Survey 3.0: Coordination of Care | Agency for Healthcare Research and Quality
     www.ahrq.gov/cahps/surveys-guidance/item-sets/cg/suppl-coordination-of-care-cg-adult.html
     April 01, 2018 - Some items cover events that occur with low frequency in the general population.

163. 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

164. 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

165. 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

166. Chapter 2: Five Key Recommendations To Improve Patient Safety for LEP Patients | Agency for Healthcare Research and Quality
     www.ahrq.gov/health-literacy/professional-training/lepguide/chapter2.html
     September 01, 2020 - engage in a systematic approach to better identify and prevent medical errors and adverse events that occur … Medical Errors Among LEP Patients Background To accurately identify and analyze medical errors that occur … need of improvement to ensure that staff are empowered and can identify and report medical errors that occur … not receive training on what constitutes an error or a near miss, or on how to report these when they occur … Hospitals rarely analyze events that occur among culturally diverse and LEP patients.

167. Sensemaking and Learn From Defects for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/perinatal-care/modules/teamwork/learn-from-defects-fac-guide.html
     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

168. 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

169. TeamSTEPPS, Module 11 (Instructor Guide) (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module11/igimplement.pdf
     March 04, 2014 - Write down the process steps as they currently occur and identify who is doing what, when, and with … ” – Outcome aims focus on changes that occur because your staff carries out the intervention. … Write down the process steps as they currently occur and identify who is doing what, when, with what … attend the training sessions; – What skills you will teach; – When the training sessions will occur … and for how long; – Where the sessions will occur; – How you will train (method of presentation

170. Implementation (Instructor Guide) (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module11/ts2-0ltc_module11_ig_implementation.pdf
     June 26, 2017 - Write down the process steps as they currently occur and identify who is doing what, when, and with … ” – Outcome aims focus on changes that occur because your staff carries out the intervention. … Write down the process steps as they currently occur and identify who is doing what, when, with what … will attend the training sessions; – What skills you will teach; – When the training sessions will occur … and for how long; – Where the sessions will occur; – How you will train (method of presentation, tools

171. Changing-System-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-facilitator-guide.docx
     June 01, 2021 - Slide 4 Active Failures SAY: Active failures occur because of human error. … Swiss Cheese Model SAY: Let’s return to our “Swiss cheese model” to help visualize where mistakes can occur … As you can see, along the process of an antibiotic prescribing decision, latent failures can occur if … Without these defenses, an “active” or human failure can occur, resulting in a poor outcome. … Change cannot occur if the workforce is not aware and engaged, so share the results from your hard work

172. 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

173. Supplemental Items for the CAHPS Clinician & Group Adult Survey 3.0: Health Promotion & Education | Agency for Healthcare Research and Quality
     www.ahrq.gov/cahps/surveys-guidance/item-sets/cg/suppl-healthpromotion-cg30-adult.html
     December 01, 2018 - Some items cover events that occur with low frequency in the general population.

174. Four Moments Poster (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/four-moments/poster-one-option.pdf
     November 01, 2019 - Four Moments Poster AHRQ Pub. No. 17(20)-0028-EF November 2019 Moment 1 occurs at the time initiation of antibiotic therapy is considered: Ask, “Does my patient have an infection that requires antibiotics?” occurs when the dec…

175. Introduction to Diagnostic Errors | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-cognitive-load1.html
     May 01, 2024 - being given to cognitive load theory (CLT), an educational model for how human memory and processing occur

176. SOPS Program Updates During the COVID-19 Pandemic | Agency for Healthcare Research and Quality
     www.ahrq.gov/sops/events/covid-19-info.html
     July 01, 2020 - addition, we note the following schedule adjustments: Data submission to the SOPS Hospital Database will occur … SOPS Hospital Database : (Update as of 6/2/2020) Data submission will occur October 1–30, 2020.

177. TeamSTEPPS Team Leadership Module 2
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/curriculum/teamstepps-module-2-slides.pptx
     February 28, 2022 - the components and composition of a multi-team system. 3 3 Team Structure Teamwork cannot occur … Where did the breakdowns occur between the components of this multi-team system? … Leadership Debriefs foster process improvement: Brief, informal information exchange and feedback sessions Occur

178. Morningbriefing (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/morningbriefing.doc
     August 07, 2012 - physicians and nurses identify the problems that occurred during the night and potential problems that may occur

179. 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,

180. Conducting a Morning Briefing | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/toolkit/morning-briefing.html
     December 01, 2012 - physicians and nurses identify the problems that occurred during the night and potential problems that may occur