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www.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?
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psnet.ahrq.gov/issue/preventable-harm-occurring-critically-ill-children
September 28, 2010 - Study
Preventable harm occurring to critically ill children.
Citation Text:
Larsen G, Donaldson AE, Parker HB, et al. Preventable harm occurring to critically ill children. Pediatr Crit Care Med. 2007;8(4):331-336.
Copy Citation
Format:
Google Scholar PubMed BibTeX EndNot…
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www.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?
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www.ahrq.gov/hai/tools/clabsi-cauti-icu/implement/playbook.html
February 01, 2025 - CUSP can be implemented through CLABSI and CAUTI prevention practices, policies, and procedures that occur
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/fmea-analysis
January 01, 2023 - mode and effects analysis (FMEA) is a method that attempts to identify all possible failures that can occur … For each function, IDENTIFY ALL THE WAYS FAILURE COULD OCCUR - i.e. the potential failure modes. … This is an estimate of the likelihood the failure will occur, and is rated on a scale from 1 to 10, with
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psnet.ahrq.gov/issue/prevalence-and-economic-burden-medication-errors-nhs-england
September 11, 2018 - Prior research has shown that medication errors occur frequently and are associated with a longer hospital … The authors estimate that 237 million medication errors occur annually and that 66 million of these errors … The majority of potentially harmful errors likely occur in the outpatient setting where most medications
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www.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?
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psnet.ahrq.gov/node/46827/psn-pdf
March 14, 2018 - Prior research has shown that
medication errors occur frequently and are associated with a longer hospital … The authors estimate that 237
million medication errors occur annually and that 66 million of these … The
majority of potentially harmful errors likely occur in the outpatient setting where most medications
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/distributed-cognition-er-nurses5.html
August 01, 2022 - Thus, it is no wonder that diagnostic errors occur.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Wakefield2.pdf
January 01, 2003 - Five
subscales emerged for “reasons why MAE occur”; four subscales emerged for
“reasons why MAE are … medication
administration errors occur. … Reasons why medication errors occur (19 items in 1994 and 29 in
subsequent surveys).
2. … In the first content area, “why MAEs occur,” five factors emerged. … Nurses’ perceptions of why medication administration
errors occur.
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/facslides.html
December 01, 2017 - Nursing homes investigate adverse events after they occur. … Is it possible to intervene before adverse events occur? … Communication: Reviews existing team meetings/huddles that occur at the facility. … When will the meeting occur?
Which report(s) will be used at the meeting? … How will communication occur with other disciplines to confirm changes in care?
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/factraining-slides.html
October 01, 2017 - Nursing homes investigate adverse events after they occur. … Is it possible to intervene before adverse events occur? … Analysis: Reviews process for conducting investigations or root cause analyses when adverse events occur … When will the meeting occur?
Which reports will be used at the meeting? … How will communication occur with other disciplines to confirm changes in care?
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/facslides.html
September 01, 2017 - Nursing homes investigate adverse events after they occur. … Is it possible to intervene before adverse events occur? … Communication: Reviews existing team meetings/huddles that occur at the facility. … When will the meeting occur?
Which reports will be used at the meeting? … How will communication occur with other disciplines to confirm changes in care?
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/wetterneck-tb-lapin-ja
January 01, 2023 - We developed a comprehensive list of primary care physician tasks that occur during a face-to-face patient … Objective
To develop a comprehensive but generic task list of primary care physician (PCP) tasks that occur
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/fallpxoverview.pptx
October 01, 2017 - Nursing homes investigate adverse events after they occur. … Is it possible to intervene before adverse events occur? … Analysis: Reviews process for conducting investigations or root cause analyses when adverse events occur … When will the meeting occur?
Which reports will be used at the meeting? … How will communication occur with other disciplines to confirm changes in care?
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-factraining-slides.pptx
November 01, 2016 - Nursing homes investigate adverse events after they occur. … Is it possible to intervene before adverse events occur? … Analysis: Reviews process for conducting investigations or root cause analyses when adverse events occur … When will the meeting occur?
Which report(s) will be used at the meeting? … How will communication occur with other disciplines to confirm changes in care?
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psnet.ahrq.gov/node/836808/psn-pdf
March 30, 2022 - medication-safety-emergency-department-study-serious-medication-errors-
reported-101-hospitals
Medication errors can occur … Errors were more likely to occur on weekends and between 12:00 pm and midnight; patients were more
likely
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psnet.ahrq.gov/node/47919/psn-pdf
April 03, 2019 - They
encourage continued use of the aviation metaphor to illustrate why medical errors occur and how … when done correctly, can help health care systems identify safety hazards, regain trust after
they occur
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psnet.ahrq.gov/node/72820/psn-pdf
March 10, 2021 - persist with long-term use of CPOE systems, but future research should explore the types of errors
that occur … , when they occur, and the system factors contributing to the errors.
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/four-moments/poster-three-options.pdf
November 01, 2019 - Moment 4 should occur as soon as it is clear what infectious
process is being treated and the patient … Moment 4 should occur as soon as it is clear what infectious process is being
treated and the patient