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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?
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www.ahrq.gov/hai/pfp/hacrate2013.html
January 01, 2018 - 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013
Next Page
Table of Contents
2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013
Appendix
References
Summary
…
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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.
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www.ahrq.gov/research/publications/search.html?page=17
October 01, 2011 - Number: 10-0058-EF
10 Patient Safety Tips for Hospitals
Medical errors may occur
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www.ahrq.gov/hai/pfp/interimhacrate2013.html
November 01, 2015 - Efforts To Improve Patient Safety Result in 1.3 Million Fewer Patient Harms
Next Page
Table of Contents
Efforts To Improve Patient Safety Result in 1.3 Million Fewer Patient Harms
Appendix
References
Interim Update on 2013 Annual Hospital-Acquired Condition Rate and Estimates of Co…
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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
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/4.html
December 01, 2017 - Static Week Calculation:
Identify all weights that occur in the range of 85-95 days from the most … Static Week Calculation:
Identify all weights that occur in the range of 170-190 days from the most
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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
-
www.ahrq.gov/es/hai/universal-icu-decolonization/universal-icu-overvw.html
September 01, 2013 - existing infrastructure for quality improvement (QI) by which QI and patient safety interventions usually occur
-
www.ahrq.gov/news/newsroom/case-studies/ktcquips32.html
October 01, 2014 - There was also a 13 percent improvement in their perceptions of whether problems occur during the exchange
-
www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/resources/tools/engage/leader.html
March 01, 2017 - Healthcare-associated infections (HAIs) occur far too often in nursing homes.
-
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
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www.ahrq.gov/cahps/surveys-guidance/item-sets/cg/suppl-access-items-cg-survey30-adult.html
December 01, 2018 - Some items cover events that occur with low frequency in the general population.
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www.ahrq.gov/cahps/surveys-guidance/item-sets/cg/suppl-access-items-cg-survey30-child.html
December 01, 2018 - Some items cover events that occur with low frequency in the general population.
-
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
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www.ahrq.gov/hai/tools/mvp/modules/cusp/learn-from-defects-fac-guide.html
February 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.
-
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
-
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
-
www.ahrq.gov/practiceimprovement/delivery-initiative/ihs/chapter9.html
December 01, 2017 - for addressing distributional issues related to the outcome variables and selection bias issues that occur
-
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.