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Showing results for "occur".

141. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/857259/psn-pdf
     November 30, 2023 - 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

142. 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?

143. 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

144. 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

145. 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

146. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867676/psn-pdf
     February 26, 2025 - https://psnet.ahrq.gov/primer/responding-patient-safety-events Background Patient safety events that occur … If indicated, early compensation could occur in the form of waiving hospital bills while the healthcare … This especially tends to occur in situations where the healthcare staff bonds with a patient or family

147. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33561/psn-pdf
     September 15, 2024 - in reference to particularly shocking medical errors—such as wrong-site surgery—that should never occur … However, when Never Events occur, they are devastating to patients and may indicate a fundamental safety … A 2013 study estimated that more than 4000 surgical never events occur yearly in the United States.

148. 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

149. 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

150. 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

151. 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

152. 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

153. 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

154. 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

155. 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

156. Primers | PSNet
     psnet.ahrq.gov/primers-0
     March 15, 2025 - records in order to identify errors and adverse events, measure the frequency with which such events occur … records in order to identify errors and adverse events, measure the frequency with which such events occur … Facebook Twitter Linkedin Copy URL Patient safety events that occur … preventable, but health care systems should be able to rapidly identify and treat complications when they occur

157. Readmissions for Selected Infections Due to Medical Care: Expanding the Definition of a Patient Safety Indicator (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Gallagher2.pdf
     January 01, 2016 - • Area-level indicators identify all cases of the potentially preventable complications that occur … AHRQ developed the hospital-level PSIs to capture inpatient events that occur during a single admission … These data help estimate the volume of those adverse events that occur in the admission during which … By attributing area-level PSI cases that occur because of inpatient care to the hospital-level PSI, … Because the intent of the hospital-level indicator is to identify cases that occur after admission,

158. Assessment of Pediatric Look-Alike, Sound-Alike Substitution Errors - 2012 | Digital Healthcare Research
     digital.ahrq.gov/ahrq-funded-projects/assessment-pediatric-look-alike-sound-alike-substitution-errors/annual-summary/2012
     January 01, 2012 - AHRQ Funding Amount $100,000 Summary: Look-alike, sound-alike (LASA) medication errors occur … the drugs that the participants thought to be of high potential patient harm should a substitution occur

159. Guide Promotional Postcard (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/pfeprimarycare-infographic.pdf
     April 01, 2018 - admissions are related to an adverse drug event An estimated 160 million medication errors occur

160. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867145/psn-pdf
     November 13, 2024 - issue/technology-education-and-safety-3 Despite consummate efforts to improve safety, errors still occur