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Showing results for "occur".

81. Implementation Planning | Agency for Healthcare Research and Quality
    www.ahrq.gov/teamstepps-program/curriculum/implement/activity/plan.html
    February 01, 2024 - Write down the process steps as they currently occur and identify who is doing what, when, and with which … what you hope will be achieved, who will be involved, and when and where the improvements will occur … Outcome aims focus on changes that occur because your staff carry out the intervention. … Write down the process steps as they currently occur and identify who is doing what, when, and with … When the training sessions will occur and for how long. Where the sessions will occur.

82. Job Aid: Process Mapping (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/job-aid-process-mapping.pdf
    June 02, 2025 - 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

83. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/35588/psn-pdf
    February 03, 2011 - This theory asks the question of what should change, to what should it change, and how should change occur … Responses are framed with discussion of six thought processes that must occur at an organization for

84. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/34784/psn-pdf
    June 24, 2015 - to introduce emergency department communities to teamwork systems, teamwork failures that commonly occur … includes retrospective analysis of more than 50 incidents suggesting that nearly nine teamwork failures occur

85. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/33576/psn-pdf
    December 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

86. 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

87. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/44767/psn-pdf
    January 20, 2016 - failures-modern 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

88. 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

89. Tool 3. Clinical Care Observation Guide | Agency for Healthcare Research and Quality
    www.ahrq.gov/ncepcr/tools/obesity/obpcp-tool3.html
    May 01, 2014 - When does this counseling occur? How does this counseling occur?

90. Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: are they preventable? | PSNet
    psnet.ahrq.gov/issue/wrong-sidewrong-site-wrong-procedure-and-wrong-patient-adverse-events-are-they-preventable
    February 24, 2011 - A prior study indicated a rate of approximately 1 case per 112,000 surgeries, but WSPEs may occur in … from both mandatory and voluntary reporting systems indicates that approximately 1300 to 2700 WSPEs occur

91. 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.

92. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/36315/psn-pdf
    July 10, 2008 - A prior study indicated a rate of approximately 1 case per 112,000 surgeries, but WSPEs may occur in … from both mandatory and voluntary reporting systems indicates that approximately 1300 to 2700 WSPEs occur

93. 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.

94. Medication errors related to computerized provider order entry systems in hospitals and how they change over time: a narrative review. | PSNet
    psnet.ahrq.gov/issue/medication-errors-related-computerized-provider-order-entry-systems-hospitals-and-how-they
    April 07, 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.

95. Implementation of an Event Reporting and Learning System Leads to Improvements in Patient Safety Culture at UNC Medical Center-Fenton-Wilhelm-Amos (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/4-unc-webcast-fenton-wilhelm-amos.pdf
    August 15, 2019 - increased length of stay nor increased level of care) Probability Categories: Frequent (likely to occur … immediately or within a short period of time), Occasional (probably will occur), Uncommon (possible … to occur), Remote (unlikely to occur) How the SAC Matrix Works: When a severity category is paired

96. 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.

97. "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

98. Never Events | PSNet
    psnet.ahrq.gov/primer/never-events
    June 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.

99. Anatomy and pathophysiology of errors occurring in clinical radiology practice. | PSNet
    psnet.ahrq.gov/issue/anatomy-and-pathophysiology-errors-occurring-clinical-radiology-practice
    February 01, 2011 - Commentary Anatomy and pathophysiology of errors occurring in clinical radiology practice. Citation Text: Brook OR, O'Connell AM, Thornton E, et al. Quality initiatives: anatomy and pathophysiology of errors occurring in clinical radiology practice. Radiographics. 2010;30(5):1401-10. d…

100. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47291/psn-pdf
     October 31, 2018 - Little is known about the epidemiology of hospital suicides other than that they are rare and occur … Nationally, between 49 and 65 hospital suicides occur each year.