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Showing results for "occur".

161. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33579/psn-pdf
     September 15, 2024 - The systems approach holds that efforts to catch human errors before they occur or block them from causing … Active errors almost always involve frontline personnel and occur at the point of contact between a … In this construct, slips represent failures of schematic behaviors, or lapses in concentration, and occur … FMEA begins with identifying all the steps that must occur for a given process to occur.

162. Indwelling Urinary Catheter Maintenance Facilitator Notes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-catheter-maintenance-notes.docx
     April 01, 2022 - In addition to proper insertion, contamination can occur due to breaks in the collection system. … associated with maintaining a sterile, closed system at all times and recommends that if breaks or leakage occur … It is important to consider replacing the indwelling urinary catheter if breaks or leakage occur. … If breaks in the aseptic technique, disconnection, or leakage occur, replace the catheter using aseptic

163. TeamSTEPPS Implementation Guide (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/essentials/implguide.pdf
     March 01, 2006 - Where will it occur?  What do we hope to achieve with a TeamSTEPPS Intervention? … for the event to occur. … When does the “problem” occur? … When will the improvement occur? Within what timeframe? … When will the improvement occur? Within what timeframe?

164. TeamSTEPPS Implementation Guide (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/essentials/implguide_0.pdf
     March 01, 2006 - Where will it occur?  What do we hope to achieve with a TeamSTEPPS Intervention? … for the event to occur. … When does the “problem” occur? … When will the improvement occur? Within what timeframe? … When will the improvement occur? Within what timeframe?

165. Effect of Chronic Illness Complexity on Evidence-Based Depression Treatment (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/decision/mcc/jordan_grant.pdf
     September 01, 2013 - elderly persons with eight highly prevalent and/or high-cost chronic conditions that commonly co-occur … Considered Depression Eight highly prevalent and/or high cost chronic conditions that commonly co-occur

166. "What's psychology got to do with it?" Applying psychological theory to understanding failures in modern healthcare settings. | PSNet
     psnet.ahrq.gov/issue/whats-psychology-got-do-it-applying-psychological-theory-understanding-failures-modern
     July 10, 2017 - Despite widespread efforts to improve health care safety, medical errors continue to occur. … psychology , including theories related to behavior and cognition , to understand why care failures occur

167. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45255/psn-pdf
     January 23, 2017 - Although most mistakes occur during the prescribing and transcribing stages, errors during the administration … process occur frequently as well.

168. Quick Reference Guide to TeamSTEPPS Action Planning | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps/instructor/reference/quickrefguide.html
     March 01, 2014 - achieved, who will be involved (whose behavior will change), and when and where the change will occur … Write the process steps as they currently occur, identifying who is doing what, when, with what tools … each trainee audience, including who will attend, what will be taught, when and where sessions will occur

169. Job Aid: Process Mapping (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/job-aid-process-mapping.pdf
     May 17, 2021 - specific actions of different individuals (or departments) in the process and the places where handoffs occur … Remind participants to use appropriate symbols, stack actions that occur at same time, and reevaluate

170. Four Moments of Antibiotic Decision Making | Agency for Healthcare Research and Quality
     www.ahrq.gov/antibiotic-use/acute-care/four-moments/index.html
     November 01, 2019 - This can occur as early as after the first day the patient is on antibiotics; thus, the Moment 3 questions … Moment 4 should occur when the patient’s diagnosis becomes clear.

171. Sizing Up the Culture Exercise Sheet
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module4/ts2-0ltc_module4_slides_lead.pptx
     February 02, 2006 - of nursing that the home develop a more effective plan for responding to resident emergencies that occur … In addition, because these events do not occur within a unit, but involve residents and staff from multiple … the Team’s Performance: Debrief Process Improvement Short information exchange and feedback sessions Occur

172. 130-Ss-Swiss-Cheese-Fg (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/130-ss-swiss-cheese-fg.docx
     April 01, 2025 - pioneering safety researcher, described the “Swiss cheese model” to illustrate how system failures occur … Active failures occur when an “operator” performs an unsafe action that leads to an event. … To learn from these defects, examine the holes that lined up to enable the defect to occur. … Unfortunately, small mistakes in healthcare rarely get a system fix and are therefore often poised to occur … When the holes in the slices of cheese line up, an active failure can occur, leading to a safety event

173. Leading Teams (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module4/ts2-0ltc_module4_slides_lead.pdf
     June 12, 2017 - nursing that the home develop a more effective plan for responding to resident emergencies that occur … In addition, because these events do not occur within a unit, but involve residents and staff from … s Performance: Debrief Process Improvement � Short information exchange and feedback sessions � Occur

174. Understand-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-facilitator-guide.docx
     May 01, 2017 - Slide 3 SAY: Errors occur within the health care setting because health care professionals are human … Providers, executives, and managers need to understand why errors occur. … Errors occur because medicine is still treated as an art, not a science. … In analyzing how errors occur, frontline providers must recognize the scientific nature of medicine. … Errors also occur because systems frequently do not catch mistakes before they reach the patient.

175. Implementation Guide (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module11/ts2-0ltc_module11_impguide.pdf
     June 22, 2017 - ■ When and where will the improvements occur? … When will the training sessions occur and for how long? Where will the sessions occur?

176. Understand the Science of Safety for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/perinatal-care/modules/teamwork/understand-sci-fac-guide.html
     May 01, 2017 - Say: Errors occur within the health care setting because health care professionals are human, and humans … Providers, executives, and managers need to understand why errors occur. … Errors occur because medicine is still treated as an art, not a science. … In analyzing how errors occur, frontline providers must recognize the scientific nature of medicine. … Errors also occur because systems frequently do not catch mistakes before they reach the patient.

177. Scisafetynotes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/understand/scisafetynotes.docx
     September 04, 2012 - Slide 4 SAY: Errors occur within the health care setting because people are fallible. … Providers, executives, and managers need to understand why errors occur. … Errors occur because medicine is still treated as an art, not a science. … In analyzing how errors occur, frontline providers must recognize the scientific nature of medicine. … Errors also occur because systems frequently do not catch mistakes before they reach the patient.

178. Risk Assessment | Digital Healthcare Research
     digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/risk
     January 01, 2023 - mode and effects analysis (FMEA) is a method that attempts to identify all possible failures that can occur … developed, allowing the problems to either be avoided or a contingency plan to be in place should the error occur

179. AHRQ Workshop Bolsters New Jersey Patient Safety Act | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/ockt0504.html
     October 01, 2014 - accountable for their conduct and encouraging honest disclosure and analysis of the errors that inevitably occur … If the desired culture change is to occur, they need to know that their honest sharing of information

180. newbref
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module11/m11impguide.pptx
     February 03, 2006 - When and where will the improvements occur? … When will the training sessions occur and for how long? Where will the sessions occur?