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Showing results for "occur".

121. 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

122. 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?

123. 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

124. 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

125. Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery | PSNet
     psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery
     September 15, 2024 - wrong-procedure, wrong-patient errors" (WSPEs) are rightly termed never events —errors that should never occur … A seminal study estimated that such errors occur in approximately 1 of 112,000 surgical procedures, … It is worth noting, however, that many cases of WSPEs would still occur despite full adherence to the

126. 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?

127. Assessment of Pediatric Look-Alike, Sound-Alike (LASA) Substitution Errors - 2010 | Digital Healthcare Research
     digital.ahrq.gov/ahrq-funded-projects/assessment-pediatric-look-alike-sound-alike-lasa-substitution-errors/annual-summary/2010
     January 01, 2010 - Target Population: Pediatric * Summary: Look-alike, sound-alike (LASA) medication errors occur … Delphi process to identify pairs that are of greatest concern to pediatricians should a substitution occur … The Delphi process will occur through an online survey that was in development in 2010.

128. 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.

129. 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

130. 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

131. Claims, errors, and compensation payments in medical malpractice litigation. | PSNet
     psnet.ahrq.gov/issue/claims-errors-and-compensation-payments-medical-malpractice-litigation
     March 02, 2011 - Healthcare Research and Quality–supported study discovered that claims without clear evidence of error do occur … On the other hand, the majority of expenditures toward litigation occur in cases of errors in which compensation

132. 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

133. 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

134. 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

135. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/855058/psn-pdf
     October 31, 2023 - we think that certain units may have a patient population that may predispose workplace violence to occur … Opportunities for workplace violence occur in long-term care facilities because of their patient https … In recent years, in addition to workplace violence events that may occur in healthcare organizations … challenges with reporting and making it easier for clinicians to report acts of violence when they occur … Having reporting systems in place that facilitate the reporting of events when they actually occur is

136. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49667/psn-pdf
     October 01, 2012 - As a result, medication errors occur regularly in the ED, ranging from https://psnet.ahrq.gov/web-mm … also need to be aware of high-alert medications, which can have catastrophic consequences if errors occur … Mistakes with medications occur not because a clinician has been incompetent by making an error, but … their own risks for medication errors, it is important to acknowledge that medication errors generally occur … Medication errors generally occur as a result of system failures rather than faults produced by particular

137. 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

138. Heed this warning! Don't miss important computer alerts. | PSNet
     psnet.ahrq.gov/issue/heed-warning-dont-miss-important-computer-alerts
     May 07, 2018 - May 7, 2018 Fatal 1,000-fold overdoses can occur, particularly in neonates, by transposing … June 16, 2019 Fatal 1,000-fold overdoses can occur, particularly in neonates, by transposing

139. 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

140. Medication Mix-Up Leads to Patient Death | PSNet
     psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
     July 08, 2022 - medical errors are the third most common cause of death behind heart disease and cancer. 2 Errors can occur … hazards are prevented by barriers, but holes in the cheese represent opportunities for an error to occur … and commentary highlight the continual need for improvement, and how serious medication errors can occur … Thus, even if incorrect decisional responses are rare, they occur with sufficient frequency to impact … Workarounds occur within healthcare systems and may lead to deviations from protocols while providing