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Total Results: 2,792 records

Showing results for "occur".

261. Findings | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/candor-demo-program/plan-grants/findings.html
     August 01, 2022 - highest correlation in patient/family member and clinician responses was found in regard to failures that occur … Discrepancies were found to occur across all classes of medications. … Themes and subthemes emerging from the analysis suggest failures may occur in multiple domains of the

262. High-Hanging Fruit: Improving Transitions in Health Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Perry_49.pdf
     March 27, 2008 - (e.g., like-to-like, like-to-unlike, across specialties) and the myriad contexts within which they occur … Another benefit of ordering by “most important first” is a decreased likelihood that interruptions will occur … problems and issues, situation, and resource assessment; planning for the short and long term also can occur … sharp end” of care is that they can be tailored to the clinical work setting, where the transitions occur … low-hanging fruit.”41 Introducing enhancements to existing processes—beginning with ensuring that handoffs occur

263. AHRQ’s Safety Program for Nursing Homes: On-Time Facilitator Training | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/impguide.html
     July 01, 2017 - health, and reviews how staff evaluate the potential causes of hospitalizations and ED visits that do occur … This is in contrast to waiting for hospitalizations to occur before intervening. … If multiple meetings occur without progress by the team toward making decisions about implementing the

264. Standardizing Medication Error Event Reporting in the U.S. Department of Defense (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Nosek.pdf
     March 01, 2004 - historically on the individuals involved, rather than the systems and processes that allowed the error to occur

265. The Science of Improving Patient Safety and Identifying Defects: Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/surgery/modules/on-boarding/science-of-safety-fac-notes.html
     December 01, 2017 - Twenty-five percent of inpatient surgeries result in a complication, and about 1 million deaths occur … Errors also occur because systems frequently are not designed to catch mistakes before they reach the … claims, sentinel events, and mortality and morbidity conferences when we want to identify defects that occur

266. Ldusafety Facguide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety_facguide.docx
     May 01, 2017 - 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.

267. Exhibit 4.2. Suntown Hospital | Agency for Healthcare Research and Quality
     www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit4-2.html
     November 01, 2014 - Furthermore, additional effort invested in staff training might be needed for widespread adoption to occur

268. Mod01-Grand-Rounds-Slides (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/grandrounds/mod01-grand-rounds-slides.pdf
     April 01, 2016 - Slide 39 Say: Resolution can truly occur only after the organization has completed its investigation

269. Grand Rounds Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/grand-rounds.html
     August 01, 2022 - Slide 39 Say: Resolution can truly occur only after the organization has completed its

270. “Safeware”: Safety-Critical Computing and Health Care Information Technology (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Wears_75.pdf
     May 27, 2008 - rather only become unsafe when used in an environment in which mishaps and unacceptable losses can occur … design if possible, or if not, by preventing or minimizing their occurrence, controlling them if they occur … Accidents usually occur when factors have been forgotten or not accounted for in the software or system … necessary, which implies that there is a way to detect and communicate when safety-related incidents occur … states cannot be reached, or if they are reached, they are detected and handled safely before losses occur

271. Improving Guidelines for Nursing Home-Associated Viral Respiratory Infections | Agency for Healthcare Research and Quality
     www.ahrq.gov/funding/grantee-profiles/grtprofile-vogelmeier.html
     December 01, 2023 - that it helped them prepare and access resources; unfortunately, community engagement did not commonly occur

272. Operating Room Briefing and Debriefing Audit Tool | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/surgery/tools/applying-cusp/or-briefing-audit.html
     December 01, 2017 - Yes No When did the briefing occur?

273. 144-Cusp-Tip-Sheet-Engaging-Surgeons (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/144-cusp-tip-sheet-engaging-surgeons.docx
     April 01, 2025 - Smith very sternly said, “It’s my job to decide when hair removal should occur, not yours.” · Background

274. Tool: OR Briefing and Debriefing Audit Tool (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/tools/applying-cusp/or_briefing_audit.docx
     December 01, 2017 - ☐ Yes ☐ No When did the briefing occur?

275. Probability and the Diagnostic Pathway | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/probabilistic-thinking3.html
     September 01, 2022 - approaches to teaching diagnostic reasoning and the most common discussions of diagnosis for trainees occur … The number of positive tests that would occur in patients with disease and those without disease could

276. Chapter 4. Results and Key Findings | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/chapter4.html
     August 01, 2022 - TEP members indicated that certain reporting system functions need to occur at a national (or central … the TEP was reluctant to specify reporting system functions and activities that should or should not occur … MedWatch system, but did not provide details as to how interactions with other reporting systems would occur … specify all circumstances, caveats, and limitations for when public reporting should or should not occur

277. 004-Cusp-Learning-From-Defects (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/004-cusp-learning-from-defects.docx
     October 01, 2024 - SAY: Defects are flaws, imperfections, or problems that occurred or could occur in the clinical or operational … A contributing factor that is a major reason but does not occur often offers a potential opportunity … Slide 25 Case Example Using the Investigating a Defect Worksheet: Why Did This Defect Occur?

278. Appendix C. Site Visit Protocol | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/stpra/stpraapc.html
     April 01, 2018 - If an infection were to occur, which surgeries carry the greatest consequence for the patient (e.g., … When does the surgical briefing occur? … Did a surgical site infection occur? How could this have been prevented? … Probe: : When postoperative SSIs occur, are they reported to ASC?

279. Supplemental Items for the CAHPS Cancer Care Survey: Shared Decision Making | Agency for Healthcare Research and Quality
     www.ahrq.gov/cahps/surveys-guidance/item-sets/cancer/suppl-shared-decision-making-items.html
     March 01, 2017 - Please note: Some items cover events that occur with low frequency in the general population.

280. Final Progress Report: Safety Culture Research: Ways to improve existing methods (pdf file)
     www.ahrq.gov/sites/default/files/2024-04/etchegaray-report.pdf
     January 01, 2024 - o Debriefings must occur and focus on getting results of a survey back to frontline staff, help them … An alternative approach is to look at both catastrophes and the safety events that occur in normal function … a failure and getting resilient people to be proactive and look for potential failures before they occur … This tends to occur because:  Confirmation bias - leadership already decided what the safety issue is