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Showing results for "occur".

141. 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

142. 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

143. 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

144. 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

145. 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

146. 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

147. 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

148. 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

149. 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

150. 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.

151. 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?

152. 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

153. 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

154. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37506/psn-pdf
     March 12, 2019 - providers to the potential danger of unretrieved device fragments (UDFs), types of adverse events that may 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. 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

157. 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

158. 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

159. 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

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