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Total Results: 2,566 records

Showing results for "occurred".

161. Dashboard Information | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/npsd/data/dashboard/info.html
     June 01, 2019 - incorrect medication to take and the patient recognizes it as such and refuses to take it, an incident has occurred

162. Executive Summary | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-1.html
     June 01, 2023 - persist for many years, elicitation techniques must inquire about the impact of adverse events that occurred

163. Tool: STAR | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/teamstepps-program/curriculum/situation/tools/star.html
     June 01, 2023 - members are asked to respond to a change in a patient’s status when expected improvements have not occurred

164. Final Progress Report: Using Barcode Technology to Improve Medication Safety (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/2024-01/gandhi-report.pdf
     January 01, 2024 - beginning with planning, through development and implementation, to steady-state operations (which occurred … The break-even point for the hospital’s investment occurred in the first quarter of the fourth year, … $2.99 million (90% CI, $763,000 to $5.83 million), and the break-even point for return on investment occurred

165. Measure Dx: A Resource To Identify, Analyze, and Learn From Diagnostic Safety Events (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/publications2/files/MeasureDx-guide.pdf
     July 01, 2022 - Queries cannot confirm that a missed opportunity occurred, why it occurred, or whether it was preventable … Cases were reviewed by a multidisciplinary QI team to determine if a diagnostic error occurred. … that reached the patient but did not cause patient harm � Category D- An error occurred that reached … that may have contributed to or resulted in permanent patient harm � Category H- An error occurred … that required intervention necessary to sustain life Error, Death � Category I- An error occurred that

166. Chapter 4. Results and Key Findings | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/chapter4.html
     August 01, 2022 - The systems should capture both objective information about what occurred and more subjective information … Information collected from consumers should include where a patient safety event occurred; what contributed … submitted to relevant health care facilities (presumably facilities where events of the specified type occurred

167. Event Investigation and Analysis Guide: Appendix E | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/ape.html
     August 01, 2022 - Confirmation and Consensus Meeting Announcement Template As you may know, a patient care incident occurred

168. Learn From Defects Tool Worksheet: Central Line-Assoiated Bloodstsream Infection (CLABSI) (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/clabsi-learning-from-defects.pdf
     April 01, 2022 - (Communication Plan) Now that you have more information about how and why this CLABSI occurred, how

169. Learn From Defects Tool Worksheet: Catheter-Associated Urinary Tract Infection (CAUTI) (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cauti-learning-from-defects.pdf
     April 01, 2022 - (Communication Plan) Now that you have more information about how and why this CAUTI occurred, how will

170. A Conceptual Framework for Studying the Safety of Transitions in Emergency Care (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Behara.pdf
     January 01, 2004 - other differences in work patterns among the various hospitals, very different sorts of handovers occurred … Some occurred in the workplace, while other handovers took place what might be referred to as a “backstage … In our observations, however, only three of the eight potential combinations occurred with any frequency … nature pertained to joint handovers (i.e., involving both physicians and nurses), which almost never occurred … In the two settings that did use nurse-physician teams, however, handovers still occurred separately

171. Medication Management Transactions and Errors in Family Medicine Offices: A Pilot Study (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Lynch_37.pdf
     March 21, 2008 - cases, it was the phone or fax that was responsible for mitigating the error but not how the error occurred … For new chronic medications, errors occurred in 74.2 percent of encounters; for renewal of existing … processes occurring when the error was discovered rather than the circumstances at the time that the error occurred … mitigation event is identified, a retrospective review should track back to the encounter where the error occurred … Many of these errors might not have occurred with electronic prescribing embedded in an electronic medical

172. Action Planning Worksheets | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/teamstepps/instructor/essentials/implguide2.html
     November 01, 2018 - Skip to main content An official website of the Department of Health and Human Services Careers Contact Us Español FAQs Search all AHRQ sites Search small Search Menu …

173. Four Moments of Antibiotic Decision Making Explained (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/four-moments-explained.pdf
     June 01, 2021 - Four Moments of Antibiotic Decision Making Explained Moment 1 occurs when a resident is assessed for a change in status and there is a concern for infection. Sometimes long-term care staff recognize that something is not quite right with the resident but aren’t clear on what is wrong. The person doing the assessmen…

174. Special Considerations for Measurement of Diagnostic Safety (continued) | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/reports/issue-briefs/state-of-science-2b.html
     June 01, 2020 - events so they can review the medical record to determine if an actual or potential adverse event has occurred … Process breakdown taxonomy, 97 both of which help to identify where in the diagnostic process a problem occurred

175. Understand-Facilitator-Guide (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-facilitator-guide.docx
     May 01, 2017 - In determining the defect that occurred, teams reconstruct the timeline of the event by placing themselves

176. Patient and Family Engagement for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/pf-engagement-fac-guide.html
     July 01, 2023 - Generally, only findings that are reasonably certain to have occurred and unlikely to change should be … investigate and analyze it (e.g., a root cause analysis may be conducted) to determine whether patient harm occurred

177. Chapter 3. Description of Methods | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/chapter3.html
     August 01, 2022 - About 88 percent of the patient safety events occurred in a hospital setting. … One quarter of patient safety events occurred in an ambulatory setting and 10 percent in a long-term … patients, family members, and others to be able to report a patient safety event from the time the event occurred … Among the participants, about 91 percent reported that the event occurred in a hospital setting, 21 percent … recommendations did not guarantee a response from the health care setting where the patient safety event occurred

178. Quality Improvement Study Framework (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/implementation-guide/appendix-k-study-elements.docx
     April 13, 2017 - Include— · Frequency: How often the issue occurred in your study period · Sources: Potential reasons

179. Office-Based Teams Instructor Guide
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/officebasedcare/module11/11_ts_office_impplan-ig.pptx
     January 20, 2006 - Measure before and after you implement TeamSTEPPS to see if the desired changes occurred.  

180. Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Healthcare July 2020 Meeting Summary (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/topics/public-notes-meeting-summary-072320.pdf
     November 06, 2020 - Workgroup Summary: The latest Workgroup meeting occurred virtually on July 23, 2020, and was attended