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Total Results: 2,792 records

Showing results for "occur".

161. Improving the Safety of Heparin Administration by Implementing a Human Factors Process Analysis (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Harder.pdf
     May 19, 2003 - heparin administration procedures to identify the types and sources of potential and real errors that occur … Presentation of the protocol in this manner made it possible for an error to occur if the practitioner … It is likely that inexperience of this kind would make errors more likely to occur. … the process should be clearer and, as a result, there will be less likelihood that an error will occur … when a practitioner is highly stressed or fatigued—two conditions that occur far too frequently in

162. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module6/module6-care-for-caregiver.pptx
     May 01, 2011 - Stages 1 through 3 may occur individually or simultaneously. … The reliving of the event is also known as a “tripping” or “triggering” event and can occur when the … An example of the emotions and thoughts that can occur at this stage from a second-victim are in the … Understanding event disclosure will occur. Concerns about litigation. … The second-victim understands that disclosure of the event will occur with the patient and/or family

163. PPE
     www.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

164. Strategy 2: Communicating for Improve Quality (Tool 1) (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy2/Strat2_Tool_1_Be_Partner_508.docx
     June 02, 2025 - Nurse shift changes occur when nurses who are going off duty share information about you with nurses

165. Supplemental-Shareddecisionmaking-Cgcahps-Adult-2357-5A (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/item-sets/CG/supplemental-shareddecisionmaking-cgcahps-adult-2357-5a.docx
     June 02, 2025 - Some items cover events that occur with low frequency in the general population.

166. Medication Discrepancies and Potential Adverse Drug Events During Transfer of Care from Hospital to Home | Agency for Healthcare Research and Quality
     www.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

167. Supplemental Items for the CAHPS Cancer Care Survey: Information from Providers | Agency for Healthcare Research and Quality
     www.ahrq.gov/cahps/surveys-guidance/item-sets/cancer/suppl-provider-info-items.html
     March 01, 2017 - Please note: Some items cover events that occur with low frequency in the general population.

168. Supplemental Items for the CAHPS Clinician & Group Adult Survey 3.0: Patient-Centered Medical Home | Agency for Healthcare Research and Quality
     www.ahrq.gov/cahps/surveys-guidance/item-sets/cg/suppl-pcmh-items-cg-survey30-adult.html
     December 01, 2018 - Some items cover events that occur with low frequency in the general population.

169. Two-Day Training Content | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps-program/curriculum/intro/teach/two-day.html
     January 01, 2024 - Describe the impact of errors and why they occur. Describe the TeamSTEPPS 3.0 framework. … Describe the impact of errors and why they occur. Describe the TeamSTEPPS framework. … The team also will be safer, allowing members to more readily identify and correct errors if they occur

170. Learning From Defects Through Sensemaking: Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-fac-notes.html
     December 01, 2017 - second-order problem solving; List contributing factors that make defects in care more likely to occur … Ask: Why did the defect occur? Why did the contributing factor occur? … It did not occur to anyone that this patient could be misidentified. … Say: In the case study, why did the defect occur? … Ask: Does the factor occur rarely and does it have a high likelihood of happening again?

171. 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

172. Supplemental-Sdm-Hp-Adult-2157-5A (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/item-sets/HP/supplemental-sdm-hp-adult-2157-5a.docx
     June 02, 2025 - Some items cover events that occur with low frequency in the general population.

173. NICU Family Information Packet, Appendix B, Ostomy Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-ostomy.pdf
     June 02, 2025 - ■ Fungal infections: can occur in the warm, moist environment beneath the barrier and erode skin

174. Selected Best Practices and Suggestions for Improvement (pdf file)
     www.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

175. Appendix A: Interview Questions | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/clabsi-final/clabsifinalap.html
     January 01, 2013 - Did they occur often enough? Anything else? … Occur frequently enough? Was it by Email or phone?

176. AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/factraining.html
     December 01, 2014 - Help the team problem solve obstacles that occur during the implementation process. … to describe their process for conducting investigations or root cause analyses when adverse events occur … Some of the suggested meetings may already occur at the nursing home but may need to be restructured … When would the meeting occur? … How will communication occur with other disciplines to confirm changes in care?

177. Facilitator Guide: Learning From Defects Through Sensemaking (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects_facnotes.docx
     December 01, 2017 - and second-order problem solving; List contributing factors that make defects in care more likely to occur … ASK: Why did the defect occur? Why did the contributing factor occur? … It did not occur to anyone that this patient could be misidentified. … ASK: Does the factor occur rarely and does it have a high likelihood of happening again? … Focus on a defect that carries the greatest risk of harm to patients, is most likely to occur, and has

178. 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

179. Error Producing Conditions in the Intensive Care Unit (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Drews_15.pdf
     February 26, 2008 - Among the areas where errors occur frequently is the intensive care unit (ICU). … human error in U.S. hospitals each year.1 Critical care is one of the areas in which human errors occur … a more proactive strategy of error management; its goal is to anticipate where and how errors may occur … Our initial finding is consistent with the existing literature on error in the ICU: Errors not only occur … in the ICU, but they occur rather frequently, as reflected in the high mean nurse estimates of 6.35

180. Conclusions | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-5.html
     June 01, 2023 - diagnostic mishaps cross multiple clinical settings, half of the diagnostic problems patients report occur