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Total Results: 2,792 records

Showing results for "occur".

81. Final Progress Report: Patient Safety in Hospice Care (pdf file)
    www.ahrq.gov/sites/default/files/2024-10/smucker-report.pdf
    January 01, 2024 - and categorize the types, characteristics, and contributing factors of patient safety incidents that occur … readily identifiable, preventable, and severe potential for harm) used to define “never events” that occur … contexts of home hospice care suggest unique types and patterns of patient safety incidents that may occur … • Pain crises or other needs for sudden changes in care plans frequently occur during home hospice … Significance This proposed study resulted in the first reported descriptions of adverse events that occur

82. PowerPoint Presentation: Learn From Defects Through Sensemaking
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects.pptx
    December 01, 2017 - Why 2: Why did the answer to “Why 1” occur? Why 3: Why did the answer to “Why 2” occur? … Why 4: Why did the answer to “Why 3” occur? Why 5: Why did the answer to “Why 4” occur? … Why did the contributing factor occur? … It did not occur to anyone that this patient could be misidentified. … Does it occur rarely or have a high likelihood of reoccurring?

83. Prologue: Technology and Medication Safety (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Prologue_Grady_Vol4.pdf
    June 02, 2025 - about privacy and the security of health data, and the unintended consequences that can sometimes occur … Medication errors are a frequent cause of adverse drug events, and they can occur at any point in the

84. Introduction | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions1.html
    June 01, 2023 - Academy of Medicine. 1 An underrecognized and high-risk moment in patients’ diagnostic journeys can occur

85. University of Iowa Uses AHRQ Data to Study Ways to Lower Incidence, Costs of Sports-Related Injuries | Agency for Healthcare Research and Quality
    www.ahrq.gov/news/newsroom/case-studies/cdom0803.html
    October 01, 2014 - At least 4.3 million sports and recreational injury episodes occur each year in school-aged children … In the U.S., more than 300,000 sports-related traumatic brain injuries (TBIs) occur each year, and many

86. 6 Tk1 T2-Talking With Residents Family Members Checklist Version Final (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/nhguide/6_TK1_T2-Talking_with_Residents_Family_Members_checklist_version_Final.docx
    October 01, 2016 - There are five potential health problems that occur as a result of taking an antibiotic. 1. … Although we cannot be certain that any of these problems will occur, it is important that you and your

87. 6 Tk1 T2-Talking With Residents Family Members Checklist Version Final (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/nhguide/6_TK1_T2-Talking_with_Residents_Family_Members_checklist_version_Final.pdf
    October 01, 2016 - There are five potential health problems that occur as a result of taking an antibiotic. 1. … • Although we cannot be certain that any of these problems will occur, it is important that you and

88. TeamSTEPPS Team Leadership Module 2
    www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/curriculum/teamstepps-module-2-slides.pptx
    June 02, 2025 - the components and composition of a multi-team system. 3 3 Team Structure Teamwork cannot occur … Where did the breakdowns occur between the components of this multi-team system? … Leadership Debriefs foster process improvement: Brief, informal information exchange and feedback sessions Occur

89. Changing-System-Facilitator-Guide (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-facilitator-guide.docx
    June 01, 2021 - Slide 4 Active Failures SAY: Active failures occur because of human error. … Swiss Cheese Model SAY: Let’s return to our “Swiss cheese model” to help visualize where mistakes can occur … As you can see, along the process of an antibiotic prescribing decision, latent failures can occur if … Without these defenses, an “active” or human failure can occur, resulting in a poor outcome. … Change cannot occur if the workforce is not aware and engaged, so share the results from your hard work

90. Pre-intervention Assessment: Adapting and Implementing Patient Safety Practices in Ambulatory Care (xls file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/safetransitions/hret-preinterventionasst.xlsx
    June 02, 2025 - Assessment of Patient and Family Engagement Values and Practices Indicate how frequently the following occur … Preparation Preparing the Patient for their Next Appointment Indicate how frequently the following occur … A3 Appointments Appointments Indicate how frequently the following occur in your facility by marking … A3 The Health Care Team The Health Care Team Indicate how frequently the following occur in your facility … A3 Care Partner Care Partner Questions Indicate how frequently the following occur in your facility

91. Chapter 2. Analyze Care Delivery | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/vtguide/guide2.html
    February 01, 2016 - steps and to identify where failures—or missed chances to prevent hospital-associated VTE (HA-VTE)—occur … For those steps that occur less than 100 percent of the time, the team will want to identify things that … prioritize these failure modes and to put some effort into delving into the root causes of why they occur

92. Chapter 2. Analyze Care Delivery | Agency for Healthcare Research and Quality
    www.ahrq.gov/es/patient-safety/settings/hospital/vtguide/guide2.html
    February 01, 2016 - steps and to identify where failures—or missed chances to prevent hospital-associated VTE (HA-VTE)—occur … For those steps that occur less than 100 percent of the time, the team will want to identify things that … prioritize these failure modes and to put some effort into delving into the root causes of why they occur

93. Learn-From-Defects-Facilitator-Guide (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.docx
    May 01, 2017 - 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

94. Selected Best Practices and Suggestions for Improvement (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d4c_pdi03-foreignbody-bestpractices.pdf
    November 01, 2012 - foreign objects can include perforation of the bowel, sepsis, and even death.1 These complications can occur … o A manual inspection of the incision site should occur, along with inspection of the surrounding surgical … Education should occur upon hire, annually, and when this protocol is added to job responsibilities.5 … performing a failure mode and effects analysis to better understand the process and where breakdowns can occur

95. Selected Best Practices and Suggestions for Improvement (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4q_combo_pdi03-foreignbody-bestpractices.pdf
    November 01, 2012 - foreign objects can include perforation of the bowel, sepsis, and even death.1 These complications can occur … o A manual inspection of the incision site should occur, along with inspection of the surrounding surgical … Education should occur upon hire, annually, and when this protocol is added to job responsibilities.5 … performing a failure mode and effects analysis to better understand the process and where breakdowns can occur

96. Selected Best Practices and Suggestions for Improvement (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4b_combo_psi05-foreignbody-bestpractices.pdf
    November 01, 2012 - foreign objects can include perforation of the bowel, sepsis, and even death.1 These complications can occur … o A manual inspection of the incision site should occur, along with inspection of the surrounding surgical … Education should occur upon hire, annually, and when this protocol is added to job responsibilities.2 … performing a failure mode and effects analysis to better understand the process and where breakdowns occur

97. Selected Best Practices and Suggestions for Improvement (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4k_combo_psi14-dehiscence-bestpractices.pdf
    May 20, 2016 - Recommended Practice: Postoperative Wound Assessment • Documentation of the surgical wound should occur … 48 hours after surgery to establish a baseline.1,2,7 • Repeat assessment should occur every shift … Education should occur upon hire, annually, and when this protocol is added to job responsibilities.1

98. Access of Central Venous Catheter for Initiation of Dialysis Procedural Checklist 1a (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/esrd/procchecklist1a-access-cvc.pdf
    June 02, 2025 - gloves ☐ Hand hygiene Note: If troubleshooting or manipulation of catheter or dialysis lines must occur

99. Preface | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/reports/advances/preface.html
    July 01, 2022 - galvanized action to reduce medical errors, there was already an emerging body of knowledge on why errors occur

100. Supplemental Items for the CAHPS Clinician & Group Adult Survey: Interpreter Services | Agency for Healthcare Research and Quality
     www.ahrq.gov/cahps/surveys-guidance/item-sets/literacy/suppl-interpreter-service-items-cg-survey30-adult.html
     December 01, 2023 - Some items cover events that occur with low frequency in the general population.