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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/leadership-4.htmlJune 01, 2021 - Disparities in diagnosis occur by race, color, ethnicity, disability, sex, gender expression, gender
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxchecklists-3.htmlSeptember 01, 2020 - An example is a “debiasing” checklist that aims to reduce errors that occur due to shortcuts in the diagnostic
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4l_combo_psi15-accidentalpuncturelaceration-bestpractices.pdfMay 31, 2016 - 385,000 needlesticks and other sharps-related injuries to hospital-based health care personnel that occur … Education should occur upon hire, annually, and when this protocol is added to job responsibilities.
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www.ahrq.gov/patient-safety/resources/simulation-issue-brief3.htmlJuly 01, 2024 - Over time, as the benefits of simulation gain appreciation, fewer cancellations may occur. 16,17 Simulation
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Behara.pdfJanuary 01, 2004 - Depending on the setting and the patient’s needs, these transitions may occur many times, once, or not … Petersen reported that medication problems were more likely to occur when inpatients were being managed … Differential misunderstandings are more likely to occur in handovers involving unlike participants. … When they did occur, they were extremely limited; for example, a Transitions in Emergency Care … Virtually all ED transitions occur beneath the angled line.
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AHRQ Grant Final Progress Report: Real-Time, Wireless, Networked Feedback for Bed-Tilt Compliance (pdf file)
www.ahrq.gov/sites/default/files/2024-01/thomas1-report.pdfJanuary 01, 2024 - Abstract Purpose: Ventilator-associated pneumonia, a common nosocomial infection, has been shown to occur … situations in which healthcare workers forget to raise the bed after performing patient activities occur … the patient laterally; (iii) the 5 patient would not be comfortable; (iv) skin breakdown would occur … During these procedures, frequent interruptions occur and may cause personnel to leave bed angles out … the bed angle for patient care, a perspective that forgives small, short-duration adjustments that occur -
Pf-Engagement-Facilitator-Guide (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/pf-engagement-facilitator-guide.docxMay 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. -
www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety-fac-guide.htmlJuly 01, 2023 - Errors associated with schematic tasks are labeled "slips" and occur because of lapses in concentration … Errors associated with failures of attentional behavior are labeled "mistakes" and often occur because … Checklists are cognitive aids that have numerous practical benefits, including reducing slips that occur … In practice, steps listed may not occur sequentially.
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions2.htmlJune 01, 2023 - Diagnostic Errors and Uncertainty EDs are among the most common settings in which diagnostic error may occur … diagnostic errors and uncertainty at the time of ED-hospital admission are high risk: approximately 3 in 20 occur
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www.ahrq.gov/priority-populations/observances/hispanic-heritage/index.htmlOctober 01, 2021 - built an automated language translation tool to allow clinical evaluations of recorded interviews to occur
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www.ahrq.gov/talkingquality/translate/labels/describe.htmlJanuary 01, 2023 - The highest percentage of pressure ulcers occur in our intensive care areas where our patients have complex
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/6.htmlDecember 01, 2017 - Limited Assistance (LA) Extensive Assistance (EA) Total Dependence (Total) Activity Did Not Occur … DO NOT USE Activity Did Not Occur (NO) to calculate weekly value.
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Module 3: Script and Slides (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/problem-solving/problem-solving-facnotes.docxMay 01, 2017 - She will know that it is successful when fewer similar problems occur. … remind you that there are resources to facilitate escalation of critical, safety-related issues that may occur -
www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/management/problem-solving-fac-notes.htmlJune 01, 2017 - She will know that it is successful when fewer similar problems occur. … remind you that there are resources to facilitate escalation of critical, safety-related issues that may occur
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124-Cusp-Science-Safety-Fg (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/124-cusp-science-safety-fg.docxApril 01, 2025 - Another example is using a checklist to ensure that a standardized series of events occur each time a … Slide 15 Beyond Personal Responsibility SAY: When errors occur, it is common to focus on the actions … It is their action that enables the event to occur. … These adverse outcomes are our “defects”—the events that occur and we don’t want them to happen again -
www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module1-introduction.pptxJanuary 12, 2022 - To put it simply, errors that affect diagnosis can occur anywhere in the healthcare delivery system. … It is not surprising, therefore, that errors in the process occur. … TeamSTEPPS for Diagnosis Improvement addresses the dynamics that can occur among, physicians, nurses, … Reflection can occur in short spurts or in longer thought, depending on the situation. … The case shows how gaps in communication and care coordination can occur, despite providers’ dedication
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/pf-engagement-fac-guide.htmlJuly 01, 2023 - Slide 17: Engaging After Adverse Events Say: Adverse events occur when a patient is harmed as a … Rarely does an adverse event occur as a result of intent.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy3/Strat3_Tool_1_BSR_Broch_508.pdfJune 02, 2025 - Nurse shift changes occur when nurses who are going off duty share information about your care with
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controlling high blood pressure (pdf file)
www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/blood-pressure-flowchart.pdfJune 02, 2025 - No PATIENT NOT INCLUDED IN DENOMINATOR Yes No Did the patient’s most recent visit occur on or -
www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/cg/instructions/suppl-access_items_cg-cahps-child-survey_2358-1a.docxJune 02, 2025 - Some items cover events that occur with low frequency in the general population.
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