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Showing results for "occur".

61. Understand the Science of Safety for Perinatal Safety (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-facilitator-guide.pdf
    May 01, 2017 - SAY: Errors occur within the health care setting because health care professionals are human, and … Providers, executives, and managers need to understand why errors occur. … Errors occur because medicine is still treated as an art, not a science. … In analyzing how errors occur, frontline providers must recognize the scientific nature of medicine … Errors also occur because systems frequently do not catch mistakes before they reach the patient.

62. Selected Best Practices and Suggestions for Improvement (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d4i_pdi11-dehiscence-bestpractices.pdf
    May 17, 2016 - Recommended Practice: Conduct postoperative wound assessment • Documentation of the surgical wound should occur … 48 hours after surgery to establish a baseline.3-5 • Repeat assessment should occur every shift thereafter … Education should occur upon hire, annually, and when this protocol is added to job responsibilities.4

63. Selected Best Practices and Suggestions for Improvement (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4w_combo_pdi11-dehiscence-bestpractices.pdf
    May 17, 2016 - Recommended Practice: Conduct postoperative wound assessment • Documentation of the surgical wound should occur … 48 hours after surgery to establish a baseline.3-5 • Repeat assessment should occur every shift thereafter … Education should occur upon hire, annually, and when this protocol is added to job responsibilities.4

64. Do Transient Working Conditions Trigger Medical Errors? (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Grayson.pdf
    January 01, 2003 - whether transient changes in working conditions may precipitate errors or make errors more likely to occur … question, “Were exposures immediately preceding the case event different from those that typically occur … These events were less likely to occur during the 30 minutes preceding the error (OR = 0.14, 95% CI … the medical error than during the rest of the error shift, though they were more likely to occur on … Breaks from policy were significantly more likely to occur on the error shift but not during the 30

65. Performing a Premortem Assessment | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/mrsa-prevention/toolkit/premortem-assessment.html
    October 01, 2024 - CUSP Premortem Tool is to help the CUSP team anticipate and mitigate potential problems before they occur

66. Sensemaking and Learn From Defects for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-fac-guide.html
    July 01, 2023 - The Learn From Defects Form, which provides a standardized means to assess where defects occur and to … These conditions are the mistakes that occur without human error. … Organizational failures occur when decisional elements, such as culture,procedures, and leadership decisions … By doing this, teams are able to assign meaning to the system breakdowns that occur on their L&D unit … defects on the L&D unit, it is important for staff to understand where and how breakdowns in safety occur

67. How To Use the Toolkit | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/surgery/how-to-use.html
    December 01, 2017 - two guides address adaptive and technical work, which are both critical elements for improvement to occur

68. 148-Investigating-Defect-Lfd-Worksheet (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/148-investigating-defect-lfd-worksheet.docx
    June 02, 2025 - Enter lessons learned Why Did This Defect Occur? What Are the Top Contributing Factors?

69. Applying a Novel Organization Change Scale in a Multisite Patient Safety Initiative | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/reports/liability/brock.html
    August 01, 2017 - interventions focused on patient safety generally have not proven effective. 2-4 When success does occur … Disclosure coaches strengthen clinician confidence and allow disclosure to occur in a timely fashion. … Our organizations’ leaders and stakeholders hold a shared vision that organizational change needs to occur … organization’s leaders and stakeholders hold a shared vision of what organizational change needs to occur … organization’s leaders and stakeholders hold a shared vision of how organizational change needs to occur

70. Epidemiology of Invasive Devices and Complications | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/cauti-tools/phys-championsgd/section2.html
    October 01, 2015 - Phlebitis (inflammation of the vein) can also occur, either related to chemical irritation of the vein … Although serious events related to PVC use occur less commonly than do those related to central venous

71. Event Investigation and Analysis Guide: Appendix D | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apd.html
    August 01, 2022 - Could this type of communication failure occur in the future during normal working conditions? … Why did they occur? Is there any opportunity to overcome the barriers?

72. Best Practices in the Management of Patients With Antibiotic Allergies – Facilitator Guide (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/allergies-guide.docx
    September 01, 2022 - They occur within minutes to hours of receipt of an antibiotic. … Type 2 reactions can occur soon after antibiotics are started, but also during subsequent days and weeks … They occur after a patient had been on antibiotics for several days. … They also tend to occur after a patient has been on antibiotics for several days. … It can occur days to weeks into therapy and can vary in severity.

73. One-Pager-Influenza (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/one-pager-influenza.pdf
    June 01, 2021 - onset of fever, headache, sore throat, cough, myalgias, rhinorrhea.1-3 • Influenza testing should occur …  Active influenza surveillance should occur until at least 1 week after the last influenza case

74. AHRQ Tribal Consultation Policy | Agency for Healthcare Research and Quality
    www.ahrq.gov/cpi/about/mission/strategic-plan/tribal-consultation-policy.html
    August 01, 2014 - Policy It is the policy of AHRQ that consultation with Federally-recognized Indian Tribes will occur … Consultation shall occur on a regular basis and may occur on an "as needed" basis as well. … The Agency will also take part in the Department's annual national Tribal budget consultations which occur … Other types of meetings and/or conferences occur in which tribal leaders/representatives and Agency leaders

75. Data Measures Guide (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/vae/datameasures-guide.pdf
    January 01, 2017 - , o 3 have adverse event (9) occur, o 2 have adverse event (18) occur, and o 3 have adverse event … (20) occur. … ) occur and 30% of the patient days had adverse event (20) occur Target Accurate documentation of … (20) occur. … ) occur and 30% of the patient days had adverse event (20) occur Target Accurate documentation of

76. A Visual Computer Interface Concept for Making Error Reporting Useful at the Point of Care (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Singh_69.pdf
    April 04, 2008 - steps in developing a culture of safety is the recognition by staff and clinicians of errors that occur … These processes are recognized to occur in a cyclical fashion, as shown by the clockwise progression … system, especially with respect to errors and opportunities for errors, including errors that may occur … In the emergency room (circle no. 2), similar cycle(s) of care occur, starting with Assessment (point … , contributors that might be present, and consequences that can occur, thereby improving situational

77. AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/exercises4.html
    December 01, 2017 - ( Circle all that apply ) Identify all weights that occur in the range of 170-190 days from the … most recent weight date; select the weight closest to 180 days Identify all weights that occur in the … weight None of the above When determining Weight 30 Days Prior, first identify all weights that occur

78. 111-Ss-Cusp-Lfd-Worksheet-A3 (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/111-ss-cusp-lfd-worksheet-a3.docx
    April 01, 2025 - contributing factor Enter intervention Enter responsible staff, deadline Enter status Why Did This Defect Occur

79. 111-Cusp-Learning-From-Defects-Worksheet (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-surgery/111-cusp-learning-from-defects-worksheet.docx
    April 01, 2025 - contributing factor Enter intervention Enter responsible staff, deadline Enter status Why Did This Defect Occur

80. AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Electronic Fetal Monitoring (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/safe-electronic/tool_safe-e-fetal-monitoring.docx
    May 01, 2017 - determined, and staff should know what resources are available should a sudden change in patient status occur … Recurrent decelerations: occur with > 50% contractions in any 20-min window. … Intermittent decelerations: occur with < 50% contractions in any 20-min window. … Timing: may occur with or without contractions. … Timing: In most cases, the onset, nadir, and recovery occur after the beginning, peak, and ending of