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Showing results for "occur".

21. Selected Best Practices and Suggestions for Improvement (pdf file)
    www.cahps.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

22. Learn-From-Defects-Facilitator-Guide (doc file)
    www.cahps.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

23. Neonatal Intensive Care: All Condition Readmissions with Gestational Age Reported: Technical Specifications (pdf file)
    www.cahps.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0207-technical-specifications.pdf
    January 30, 2020 - focus on the overall quality of care of the NICU, as some of the variation in readmission rates may occur

24. Pressure Ulcer Prevention Toolkit (doc file)
    www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module4/putoolkit_module4_tools.docx
    January 01, 1995 - Friction may occur when moving a person up in bed. 43. … For persons who have incontinence, skin cleaning should occur at the time of soiling and at routine intervals … Friction may occur when moving a person up in bed. True 43. … For persons who have incontinence, skin cleaning should occur at the time of soiling and at routine intervals

25. Sensemaking and Learn from Defects for Perinatal Safety (pdf file)
    www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.pdf
    May 01, 2017 - Defects 2 • The Learn From Defects Form, which provides a standardized means to assess where defects occur … These conditions are the mistakes that occur without human error. … • Organizational failures occur when decisional elements, such as culture, procedures, and leadership … 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

26. Sensemaking and Learn From Defects for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
    www.cahps.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

27. TeamSTEPPS Fundamentals Course: Module 4. Leading Teams | Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/teamstepps/instructor/fundamentals/module4/igleadership.html
    March 01, 2019 - which information must be communicated, a leader must be clearly designated, and mutual support must occur … Did the items on this checklist occur? If not, what was not done? … When would the briefing occur? Who would be expected to attend? … In addition, information updates within the team should occur as often as necessary. … difficult to find time for such reviews in health care, TeamSTEPPS advocates that after action reviews occur

28. Pf-Engagement-Facilitator-Guide (doc file)
    www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/pf-engagement-facilitator-guide.docx
    May 01, 2017 - Slide 16 SAY: Adverse events occur when a patient is harmed as a result of receiving medical care. … Rarely does an adverse event occur as a result of intent.

29. Module 4: Event Reporting, Event Investigation and Analysis | Agency for Healthcare Research and Quality
    www.cahps.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

30. Serious Reportable Adverse Events in Health Care (pdf file)
    www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Kizer2.pdf
    December 01, 2000 - Identifying where and when in the care process mishaps occur, and changing processes of care to reduce … and the NQF formally endorsed a list of Serious Reportable Events in health care that should never occur—what … Many rare, but serious, events are cause for considerable concern when they occur. … reportable events that should be reported and investigated by all health care facilities if they occur … Excludes emergent situations that occur in the course of surgery and/or whose exigency precludes obtaining

31. Section 5, Table 3 (pdf file)
    www.cahps.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-229-section-5-table-3.pdf
    August 01, 2014 - Because rapid sterilization of blood cultures can occur within a few hours after the first antimicrobial … Sampling before antibiotic therapy is important, because sterilization of blood cultures can occur

32. 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013 | Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/hai/pfp/hacrate2013.html
    January 01, 2018 - Skip to main content An official website of the Department of Health and Human Services Careers Contact Us Español FAQs Search all AHRQ sites Search small Search Menu …

33. Four Moments of Antibiotic Decision Making | Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/antibiotic-use/long-term-care/four-moments/index.html
    August 01, 2021 - Skip to main content An official website of the Department of Health and Human Services Careers Contact Us Español FAQs Search all AHRQ sites Search small Search Menu …

34. Appendix F: PowerPoint Presentation: Executive Summary | Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/health-literacy/professional-training/lepguide/app-f.html
    September 01, 2020 - engage in a systematic approach to better identify and prevent medical errors and adverse events that occur … patient safety among LEP patients, as well as processes to analyze medical errors and near misses that occur … among LEP patients Create routine forums for analyzing cases of medical errors and near misses that occur … engage in a systematic approach to better identify and prevent medical errors and adverse events that occur

35. Chapter 1: Background on Patient Safety and LEP Populations | Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/health-literacy/professional-training/lepguide/chapter1.html
    September 01, 2020 - Medical errors can occur anywhere in the health care system: hospitals, clinics, outpatient surgery centers … event" refers to a particularly shocking medical error (such as wrong-site surgery) that should never occur … LEP patients are more likely than English-speaking patients to suffer from physical harm when errors occur … situations, which we call high-risk scenarios, where adverse events and medical errors are most likely to occur … 6 shows examples from actual patient safety reports that illustrate the delays and errors that can occur

36. Communication-Facilitator-Guide (doc file)
    www.cahps.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/communication-facilitator-guide.docx
    June 01, 2021 - This can occur after someone has had antibiotics and can be devastating in nursing home residents. … 13 Case 3: Communication SAY: Let’s walk through a final case of communication errors that can occur … The nurse does not feel comfortable with this plan and knows that serious side effects can occur on antibiotics … Slide 16 Case 3 — DESC Script SAY: Conflict can occur in teams, and it is important to know how … to handle such situations when they occur.

37. Medication Discrepancies and Potential Adverse Drug Events During Transfer of Care from Hospital to Home | Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/patient-safety/reports/liability/neumiller.html
    August 01, 2017 - Preventable adverse drug events (ADEs) have been shown to frequently occur in a variety of settings, … at least one medication discrepancy in the transition from hospital to home care, and discrepancies occur … costs were estimated to exceed $117 billion. 28 ADEs that are primarily the result of human errors occur … As discussed previously, preventable ADEs have been shown to occur frequently in a variety of settings … Conclusion Medication discrepancies frequently occur during the transition from hospital to home care

38. Suppl Pcmh-Items Cg-Cahps-Adult-Survey 2357-2A (doc file)
    www.cahps.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/cg/instructions/suppl_pcmh-items_cg-cahps-adult-survey_2357-2a.docx
    March 11, 2016 - Some items cover events that occur with low frequency in the general population.

39. Engage Patients and Families for Perinatal Safety (pdf file)
    www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/pf-engagement-facilitator-guide.pdf
    May 01, 2017 - Slide 16 SAY: Adverse events occur when a patient is harmed as a result of receiving medical care … Rarely does an adverse event occur as a result of intent.

40. Mod5-Disclosure-Checklist (pdf file)
    www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/mod5-disclosure-checklist.pdf
    April 01, 2016 - tool: Use Part I of the checklist to prepare for the initial disclosure conversation, which should occur