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Showing results for "occur".

81. 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

82. 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

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. 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…

86. 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.

87. 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?

88. 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

89. 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

90. 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.

91. 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.

92. 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

93. 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.

94. "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

95. Chapter 4. Conclusions and Next Steps | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/findings/final-reports/stpra/stpra4.html
    April 01, 2018 - As improvements in the SASD, NIS, and the SEDD databases occur, additional information regarding the … Intervention implementation can occur with or without regulatory oversight; however, the ability to hold … providers accountable for performance in these settings over time is most likely to occur with the establishment … Once the performance steps are identified, education needs to occur, with feedback that addresses the

96. 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

97. Final Report: Using Risk Models To Improve Safety With Dispensing High-Alert Medications in Community Pharmacies (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/cohen-report.pdf
    January 01, 2024 - The basic events represent 1) exposure rates, or how often certain activities occur; 2) fundamental … Prescribing an incorrect or inappropriate dose of fentanyl patches was estimated to occur in one per … Dosing ranges overlap, so out-of-range dose alerts occur infrequently. … These errors are rarely corrected if data entry verification and patient counseling do not occur. … Patient counseling was estimated to occur with 30% of patients.

98. Psn-Pdf (pdf file)
    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

99. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/49421/psn-pdf
    October 01, 2003 - Approximately 8%-9% of adverse events occur in physicians’ offices.(1) Recent studies have examined … ordered annually in primary care practices, yet little is known about how often laboratory errors occur … Because of improvements in and automation of laboratory procedures, most laboratory errors occur during … This patient verification should occur at the time a specimen is labeled, and the label should include … key issue is that outpatient clinics and labs should have methods to capture these errors when they occur

100. Monitoring for Perinatal Safety: Electronic Fetal Monitoring | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/safe-electronic-tool.html
     July 01, 2023 - 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