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Showing results for "occur".

301. Final Report: Modeling Risk and Reducing Liability through Better Communication and Teamwork (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/baker-report.pdf
     January 01, 2024 - team members, and how to communicate with patients/ families about the risks and mistakes that can occur … members to be effective team members, what this training should consist of, when this training should occur

302. Using Data Mining to Predict Errors in Chronic Disease 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-McCabe_39.pdf
     March 28, 2008 - medications and referrals to specialists; (2) scheduling moves, which stipulate when future visits will occur … Current medication move The goal of this work was to predict whether an error of omission would occur … Circled numbers identify leaf nodes where errors are predicted to occur on the next visit. … Circled numbers identify leaf nodes where errors of omission are predicted to occur on the next visit … Rather, it predicts that an error is likely to occur at the next encounter.

303. Module 4: Event Reporting, Event Investigation and Analysis | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes4.html
     August 01, 2022 - Within the first 72 hours of a CANDOR event, the following actions should occur: Schedule and complete

304. Does Medical Error Disclosure Violate the Medical Malpractice Insurance Cooperation Clause? (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Banja.pdf
     January 01, 2004 - Situations occasionally occur in which a patient suffers significant medical complications that may … Reluctance to disclose preventable harms was twice as likely to occur at hospitals having major concerns … that the insurer will refuse to cover whatever associated costs, principally from a lawsuit, might occur … insured’s actions and intentions did not appear to be motivated by ethical obligation nor did they occur … illustrates that a truthful disclosure of what happened, in and by itself and especially as it might occur

305. Developing an Effective Care Coordination System Implementation Guide
     www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/care-coordination-slides.pptx
     January 01, 2018 - Consider standardizing: Who is responsible for certain tasks When key activities will occur How specific … patient screening and who will follow up to make sure the patient has enrolled When key activities will occur … For example, specify when will the screening occur and when the conversation between the clinician … and patient/family will occur How specific activities will be performed For example, specify the

306. Lessons Learned from the Evolution of Mandatory Adverse Event Reporting Systems (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Flink.pdf
     April 09, 2004 - recommends that near misses also be included in reporting, as they represent most of the events that occur … NYPORTS allows analysis to occur at both the facility and NYSDOH levels for use in quality assurance … Analysis of NYPORTS data allows the NYSDOH and facilities to identify those areas where errors can occur … This is more likely to occur if key stakeholders help develop the system, as they will help build the … This added structure to the reports and allowed more meaningful analysis to occur.

307. Improving Error Reporting in Ambulatory Pediatrics with a Team Approach (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Neuspiel_43.pdf
     March 05, 2008 - by resident physicians. 1 Limited information is available about the types of errors that occur … Since the vast majority of health care encounters with children occur on an outpatient basis, an understanding … Prior studies cited above suggest that medication errors alone may occur in 15 to 22 percent of outpatient

308. Creating a Culture of Patient Safety through Innovative Hospital Design (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Reiling.pdf
     January 01, 2004 - Churchill According to the Institute of Medicine (IOM),1 tens—if not hundreds—of thousands, of errors occur … The majority of errors that occur are considered “near misses”—errors that could have caused harm to … The IOM reported that the probability of a hospital preventable medical death will occur in the range … of 3 to 6 per 1,000 admissions and that an adverse event will occur in the range of 3 to 4 per every … In these types of activities, errors known as slips or mistakes (lapses) can occur for multiple reasons

309. Facilitator-Notes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module4/facilitator-notes.docx
     March 01, 2017 - SLIDE 16 SAY: Handoffs occur during a change in assignment for the responsibility of caring for a … A handoff may occur when a resident is first welcomed to the nursing home from the hospital or during … another staff member, even for a short timespan such as a lunch break, a structured communication should occur

310. Cusp Patient Family Engagement Facilitator Notes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/patfamilyengagement/CUSP_Patient_Family_Engagement_Facilitator_Notes.docx
     June 02, 2025 - consider: · Planning and design · Everyday care · After an adverse event Slide 21 SAY: Adverse events occur … Rarely does an adverse event occur as a result of intent.

311. On-Time Pressure Ulcer Healing: Facilitator Training Instructor's Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/guide.html
     December 01, 2017 - Communicate risk changes as they occur. … Improve 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?

312. Module 5: Response and Disclosure | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/notes.html
     August 01, 2022 - not an isolated event, since there are many different points at which disclosure conversations can occur

313. Facilitator Guide: Science of Safety Training & Identifying Defects (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_scienceofsafety_facnotes.docx
     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

314. A Model-based Approach to Prioritizing Medical Safety Practices (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Marken.pdf
     January 01, 2004 - tests have been rare.7 One reason for the lack of testing is the actual rate at which medical errors occur … Prescribing errors, for example, occur in 0.4 percent to 1.9 percent of all medication orders, and … Since medical safety practices are applied to the problem of eliminating the errors that occur when … practices are carried out, as well as by psychological theories regarding human errors and why they occur … Preventing medications errors that occur in the home. US Pharm 2004;9:64-8. 43.

315. Quantitative and Qualitative Analysis of Medication Errors: The New York Experience (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Duthie.pdf
     January 01, 2004 - Rare or unfamiliar circumstances compounded the potential that an adverse event would occur. … failure-to-rescue type events may help hospitals to undertake proactive steps so that, when an error does occur

316. Using Probabilistic Risk Assessment to Model Medication System Failures in Long-term Care Facilities (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Comden.pdf
     January 01, 2003 - drug, wrong-dose, omitted-dose/drug, and wrong-patient medication errors) were modeled because they occur … wrong dose on order Q:0.001 Gate363 Read back occurs and fails Q:0.28 Event593 Read back does not occur … wrong dose on order Q:0.001 Gate363 Read back occurs and fails Q:0.28 Event593 Read back does not occur … These practices are generally forbidden in P&Ps, but this study found that they occur with some frequency … Too often, when adverse events occur, health care professionals lack the time and/or resources to thoroughly

317. Implementation Steps and Timeline | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/impsteps.html
     January 01, 2017 - Monthly After about 6 months, the facilitator’s role is to check in to identify obstacles that could occur … The expectation is that reports will be used on a weekly basis except for meetings that occur less frequently

318. 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/timeline.html
     June 01, 2017 - Monthly After about 6 months, the Facilitator’s role is to check in to identify obstacles that could occur … The expectation is that reports will be used on a weekly basis except for meetings that occur less frequently

319. Final Progress Report: Developing biomechanical models from initiated fall actions and reactions in frail elderly patients (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/morse-merryweather-report.pdf
     January 01, 2024 - For high-fall-risk individuals, the largest number of CBs generally occur during the Stand Initiation … The highest number of CBs on average occur for those at high fall risk in every STSW phase when exiting

320. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/learn-from-defects-facguide.docx
     January 01, 2017 - second-order problem solving, list the contributing factors that make defects in care more likely to occur … ASK: Does the defect occur rarely or have a high likelihood of returning? … SAY: Focus on a defect that carries the greatest risk of harm to the patients, is most likely to occur … As a general rule, consider factors that occur often as major reasons for the defect.