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Showing results for "occur".

221. Understand the Science of Safety for Perinatal Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-facilitator-guide.pdf
     May 01, 2017 - SAY: Errors occur within the health care setting because health care professionals are human, and … 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.

222. Appendix A. Atlas Perspective and Domain Definitions | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/pcpaccountability/pcpaccapa.html
     July 01, 2018 - Communication may occur through a wide variety of channels, but for the purposes of measurement, we distinguish … While in practice interpersonal communication and information transfer often occur together, for the … Efforts aimed at specific transitions, which occur when information about or accountability for some

223. Acute Care Asymptomatic Bacteriuria and Urinary Tract Infections
     www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/allergies-slides.pptx
     September 01, 2022 - testing or evidence of hemolysis (jaundice, dark urine) or thrombocytopenia (petechiae) Most commonly occur … Serum sickness Vasculitis Palpable purpura Joint pain Urticaria Lymphadenopathy Fevers Most commonly occur … Ambulatory Care Allergy History: Timing3,12 How long after starting the antibiotic did the reaction occur … Type 1 allergies occur after the first or second dose Other types usually occur days later How long … ago did the reaction occur?

224. Acute Care Asymptomatic Bacteriuria and Urinary Tract Infections
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/allergies-slides.pptx
     September 01, 2022 - testing or evidence of hemolysis (jaundice, dark urine) or thrombocytopenia (petechiae) Most commonly occur … Serum sickness Vasculitis Palpable purpura Joint pain Urticaria Lymphadenopathy Fevers Most commonly occur … Ambulatory Care Allergy History: Timing3,12 How long after starting the antibiotic did the reaction occur … Type 1 allergies occur after the first or second dose Other types usually occur days later How long … ago did the reaction occur?

225. Presentation: Program Overview
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/learn-from-defects-slides.pptx
     January 01, 2017 - and second-order problem solving List contributing factors that make defects in care more likely to occur … you identify contributing factors Use the “5 Whys” technique Why 1—Why did this contributing factor occur … Why 2—Why did “Why 1” occur? Why 3—Why did “Why 2” occur? Why 4—Why did “Why 3” occur? … Why 5—Why did “Why 4” occur? … Does it occur rarely or have a high likelihood of reoccurring?

226. Looking for Meds in All the Wrong Places | PSNet
     psnet.ahrq.gov/web-mm/looking-meds-all-wrong-places
     June 16, 2021 - As a result, medication errors occur regularly in the ED, ranging from about 5.4 to 16.1 medication errors … 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

227. 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

228. Human Factors in Surgery: Shifting the Paradigm on Patient Safety | Agency for Healthcare Research and Quality
     pbrn.ahrq.gov/funding/grantee-profiles/grtprofile-catchpole.html
     December 01, 2022 - 4,000 annual “never events”—shocking medical errors, such as wrong-site surgery, that should never occur … Delivery  , focuses on reducing the 200,000 to 20 million anesthesia-related medication injuries that occur … Factors and Systems Integration in High Technology Surgery , explores the root causes of errors that occur

229. Human Factors in Surgery: Shifting the Paradigm on Patient Safety | Agency for Healthcare Research and Quality
     pcmh.ahrq.gov/funding/grantee-profiles/grtprofile-catchpole.html
     December 01, 2022 - 4,000 annual “never events”—shocking medical errors, such as wrong-site surgery, that should never occur … Delivery  , focuses on reducing the 200,000 to 20 million anesthesia-related medication injuries that occur … Factors and Systems Integration in High Technology Surgery , explores the root causes of errors that occur

230. Office-Based Teams Instructor Guide
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/officebasedcare/module11/11_ts_office_impplan-ig.pptx
     January 20, 2006 - Write down the process steps as they currently occur and identify who is doing what, when, and with what … Outcome aims focus on changes that occur because your staff carries out the intervention. … Write down the process steps as they currently occur and identify who is doing what, when, and with what … Who will attend the training sessions; What skills you will teach; When the training sessions will occur … and for how long; Where the sessions will occur; How you will train (method of presentation, tools,

231. 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

232. 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

233. Module 2 Slides
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module2/ts2-0ltc_module2_slides_teamstructure.pptx
     February 02, 2006 - system TEAMSTEPPS 05.2 Mod 2 LTC 2.0 Page ‹#› Team Structure 2 Team Structure Teamwork cannot occur … Core team Coordinating team Contingency team Ancillary and support services Where did the breakdowns occur

234. Assessment of Pediatric Look-Alike, Sound-Alike Substitution Errors (pdf file)
     digital.ahrq.gov/sites/default/files/docs/activity/2011_018841_basco_pdf_3.pdf
     January 01, 2011 - March 2012 AHRQ Funding Amount: $100,000 Summary: Look-alike, sound-alike (LASA) medication errors occur … The respondents are asked: “Please score the severity of the potential harm that might occur from not … identifying drugs that the participants felt were of high potential harm to a patient should a substitution occur

235. 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

236. Chapter 6. Discussion and Policy Implications | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/consumer-exp/reporting/chapter6.html
     October 01, 2014 - indicated that the consumer perspective may be particularly important for patient safety events that occur … system features (often substantially removed from the consumer) that enabled a patient safety event to occur … attempt to both prevent patient safety events from occurring and understand the causes of events that do occur … This may particularly apply to patient safety events that occur in outpatient settings, where there is … Decisions regarding system functions/activities that occur at the "system hub" versus those that occur

237. Supplemental-Policyholder-Hp-Adult-2157-16A (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/item-sets/HP/supplemental-policyholder-hp-adult-2157-16a.docx
     December 08, 2017 - Some items cover events that occur with low frequency in the general population.

238. Do Transient Working Conditions Trigger Medical Errors? (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Grayson.pdf
     January 01, 2003 - whether transient changes in working conditions may precipitate errors or make errors more likely to occur … question, “Were exposures immediately preceding the case event different from those that typically occur … These events were less likely to occur during the 30 minutes preceding the error (OR = 0.14, 95% CI … the medical error than during the rest of the error shift, though they were more likely to occur on … Breaks from policy were significantly more likely to occur on the error shift but not during the 30

239. 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

240. Learn From Defects in Care of Mechanically Ventilated Patients: Slide Presentation | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/hai/tools/mvp/modules/cusp/learn-from-defects-slides.html
     February 01, 2017 - List contributing factors that make defects in care more likely to occur. … Why 1—Why did this contributing factor occur? Why 2—Why did “Why 1” occur? … Why 3—Why did “Why 2” occur? Why 4—Why did “Why 3” occur? Why 5—Why did “Why 4” occur? … Does it occur rarely or have a high likelihood of reoccurring?