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Showing results for "occur".

341. The Nature, Characteristics and Patterns of Perinatal Critical Events Teams (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Riley_58.pdf
     April 02, 2008 - We selected obstetrics crises to study team performance for several reasons: • They occur in a compressed … regarding the nature of team formation and reformation in health care and leadership transfer that occur … At the same time, more complications/crisies could occur in real life situations.

342. Preparing for Ambulatory Computerized Prescriber Order Entry by Evaluating Preimplementation Medication Errors (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Devine.pdf
     July 01, 2003 - ambulatory care setting is complex, and that there are numerous points in that process where errors can occur

343. Final Progress Report: Pediatric Medication Safety: Analyses from the MEDMARX Medication Error Reporting System (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/bundy-report.pdf
     January 01, 2024 - Categories B through D errors involved situations in which an error did occur, but no harm resulted … suggest that, by targeting these risk factors for harm in the NICU, a significant number of errors that occur

344. Silence A Commentary | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/liability/silence.html
     August 01, 2017 - Yet, when harm does occur, and honest and transparent conversations are not conducted, you harm us again

345. The Contribution of Diagnostic Error to Maternal Mortality and Severe Maternal Morbidity | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/maternal-mortality-2.html
     September 01, 2021 - Communication breakdowns can occur between patients and providers and within the healthcare team in an

346. Making the Case That Improving Antibiotic Use Is a Patient Safety Issue (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/patient-safety-facilitator-guide.pdf
     November 01, 2019 - Often, these adverse events occur after a patient is discharged from the hospital. … The holes are the errors in your system that occur and risk harming a patient. … Moment 4 should occur as soon as it is clear what infectious process is being treated and the patient

347. Module 4: Teamwork and Communication: Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module4/mod4-facguide.html
     March 01, 2017 - Slide 17: For Information Transfer – Handoffs Say: Handoffs occur during a change in assignment … 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

348. Patient and Family Engagement | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/modules/patient-family-engagement/notes.html
     September 01, 2013 - Introduction to Adverse Events Say: Adverse events occur when a patient is harmed as a result of … Rarely does an adverse event occur as a result of intent.

349. Learning-From-Antibiotic-Adverse (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/learning-from-antibiotic-adverse.docx
     June 01, 2021 - AHRQ Safety Program for Improving Antibiotic Use Learning From Antibiotic-Associated Adverse Events An antibiotic-associated adverse event is any event or situation that you would not want to happen again because it either caused your patient harm or had the potential to cause harm. The purpose of this tool is to provi…

350. AHRQ Quality and Safety Review System (QSRS) | Agency for Healthcare Research and Quality
     www.ahrq.gov/cpi/about/otherwebsites/qsrs.ahrq.gov/index.html
     March 01, 2021 - AHRQ Quality and Safety Review System (QSRS) Mission AHRQ has developed and tested an improved patient safety surveillance system to replace the Medicare Patient Safety Monitoring System (MPSMS). The new system is known as the Quality and Safety Review System (QSRS). The QSRS relies on clinical information re…

351. System-Focused Event Investigation and Analysis Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4.html
     August 01, 2022 - In addition, learning about system vulnerabilities before they occur is critical. … The CANDOR Response Team is responsible for conducting a preliminary review, which should occur within … The preliminary review should occur at the event location. … understanding of the event: if individual interviews, appropriate information gathering, and observations occur … Please note that the bulk of the time and effort of the event review process should occur during the

352. Transitioning Newborns from NICU to Home: Family Information Packet, Appendix B (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb.pdf
     June 02, 2025 - ■ UTI and urolithiasis do not occur any more frequently than in general population. … – Earlier followup should occur if poor weight gain, difficulty feeding, and tachypnea develop. … ■ Fungal infections: can occur in the warm, moist environment beneath the barrier and erode skin … – Sporadic motor movements may occur with low muscle tone between these movements. … ■ Tracheo-esophageal fistula may occur as a result of posterior wall erosion.

353. Evaluation of Medications Removed from Automated Dispensing Machines Using the Override Function Leading to Multiple System Changes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Miller_93.pdf
     March 12, 2008 - It might also occur if staff has a verbal order and acts upon it, or if a physician demands that a medication

354. Chipra202-Materials Iiia (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/CHIPRA202-Materials_IIIA.pdf
     January 01, 2014 - Organizations may count services that occur over multiple visits toward this measure as long as all … of the services occur within the time frame established in the measure.

355. Chipra204-Materials Iiia (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/CHIPRA204-Materials_IIIA.pdf
     January 01, 2014 - Organizations may count services that occur over multiple visits toward this measure as long as all … of the services occur within the time frame established in the measure.

356. Chipra205-Materials Iiia (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/CHIPRA205-Materials_IIIA.pdf
     January 01, 2014 - Organizations may count services that occur over multiple visits toward this measure as long as all … of the services occur within the time frame established in the measure.

357. Mod4-System-Focused-Event-Guide (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4/mod4-system-focused-event-guide.pdf
     April 01, 2016 - In addition, learning about system vulnerabilities before they occur is critical. … The CANDOR Response Team is responsible for conducting a preliminary review, which should occur within … The preliminary review should occur at the event location. … Please note that the bulk of the time and effort of the event review process should occur during the … Why did they occur? ■ Is there any opportunity to overcome the barriers? ■ If not, why?

358. Final Progress Report: Unexpected Clinical Events: Impact on Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-12/weinger2-report.pdf
     January 01, 2024 - patient safety, it is critical to understand how clinical systems actually work and why adverse events occur … systems actually work, what factors make them work well (or not so well), and why adverse events occur … When adverse events do occur, it may be difficult retrospectively to accurately determine their etiology … it proved unnecessary during the data review process in this project, remediation of reviewers may occur … Studies have shown that NRE 1) occur frequently and are of diverse type; 2) are commonly associated

359. Applying the AHRQ Pediatric Quality Indicators to Hospital Data (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/b1_pdi_applyingpdis.pdf
     March 01, 2016 - for that specific indicator Expected events = for each PDI, the total sum of events expected to occur … by the size of your hospital’s patient population and the types of quality and safety events that occur … eligible hospital stay is assigned an expected probability that a particular indicator event will occur

360. Applying the AHRQ Quality Indicators to Hospital Data (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/b1_combo_applyingqis.pdf
     March 01, 2016 - that specific indicator Expected events = for each QI indicator, the total sum of events expected to occur … by the size of your hospital’s patient population and the types of quality and safety events that occur … eligible hospital stay is assigned an expected probability that a particular indicator event will occur