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Total Results: 4,281 records

Showing results for "occurred".

101. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-pediatric-safety-1.html
     August 01, 2023 - focus of pediatric research, particularly in tertiary children’s hospitals. 6-11 Less exploration has occurred

102. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-pediatric-safety-1.html
     August 01, 2023 - focus of pediatric research, particularly in tertiary children’s hospitals. 6-11 Less exploration has occurred

103. Appendix 8: CLABSI Investigation Nurse Letter | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/clabsi-tools/appendix-8.html
     March 01, 2018 - Because the event occurred more than 48 hours from the time of line insertion, it is clear that this

104. Board Checklist | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/perinatal-care/modules/teamwork/board-checklist.html
     May 01, 2017 - Discuss major patient safety events/errors that have occurred in the most recent timeframe to show that

105. Board Checklist | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/toolkit/board-checklist.html
     December 01, 2012 - Discuss major patient safety events/errors that have occurred in the most recent timeframe to show that

106. Conclusion | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-5.html
     June 01, 2023 - situations that pose the greatest challenges for patients and families to reliably assess what has occurred

107. Conclusion | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-5.html
     June 01, 2023 - situations that pose the greatest challenges for patients and families to reliably assess what has occurred

108. Chapter 2. Fall Response | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man2.html
     December 01, 2017 - Unless there is evidence suggesting otherwise, the most logical conclusion is that a fall has occurred … distance to the next lower surface (in this case, the floor) is not a factor in determining whether a fall occurred … , an immediate intervention should be put in place by the nurse during the same shift that the fall occurred

109. Facilitator Guide: Learning From Defects Through Sensemaking (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects_facnotes.docx
     December 01, 2017 - So, first look at the system and analyze why the mistake occurred. … What actions occurred? What were the team members thinking and feeling? … SAY: These are the types of questions to ask to understand how a defect occurred. … Try to find out exactly how things occurred in real time. Slide 13 What Happened? … No timeouts or debriefings occurred. NOTE: Spend 10 to 15 minutes discussing the case.

110. Learning From Defects Through Sensemaking: Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-fac-notes.html
     December 01, 2017 - So, first look at the system and analyze why the mistake occurred. … What actions occurred? What were the team members thinking and feeling? … Say: These are the types of questions to ask to understand how a defect occurred. … Try to find out exactly how things occurred in real time. Slide 14: What Happened? … No timeouts or debriefings occurred. Note: Spend 10 to 15 minutes discussing the case.

111. AHRQ Safety Program for Perinatal Care: Board Checklist (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/supporting/board-checklist.docx
     May 01, 2017 - Discuss major patient safety events/errors that have occurred in the most recent timeframe to show that

112. Table 26. Utilization of education and case management service by type of visit among adults with diabetes who had at least one visit. Fiscal year 2010 | Agency for Healthcare Research and Quality
     www.ahrq.gov/practiceimprovement/delivery-initiative/ihs/chap6tab26.html
     December 01, 2017 - 33.1% 36.7% 3.8% 9.3% 100.0% 38.9% a Diabetes education visits are visits that occurred

113. Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/studies/index.html?page=7
     January 01, 2024 - Delirium occurred in 15.6% of admissions, with lower rates observed for ACSC admissions compared to non-ACSC … Severe desaturation or severe TIAE occurred in 23.7% of nasal and 22.5% of oral TI. … in 11-20% of their cases, 14.5% reported that this occurred in 21-50% of their cases and 4.8% reported … that this occurred in over 50% of their cases. … TIAEs and/or hypoxemia occurred more often in underweight (27.1%) and obese (24.3%) patients.

114. 004-Cusp-Learning-From-Defects (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/004-cusp-learning-from-defects.docx
     October 01, 2024 - SAY: Defects are flaws, imperfections, or problems that occurred or could occur in the clinical or operational … Even if the MRSA represents colonization and no infections have occurred, this indicates an infection … prevention lapse occurred, and the patient is at increased risk of developing a MRSA infection. … · What actions occurred? · What were people thinking and feeling? … · What else was happening at the time the defect occurred?

115. Leading Teams (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module4/ts2-0ltc_module4_slides_lead.pdf
     June 12, 2017 - When emergencies have occurred at these events in the past, many people come running and there is … � Designed to improve outcomes � An accurate recounting of key events � Analysis of why the event occurred

116. Sizing Up the Culture Exercise Sheet
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module4/ts2-0ltc_module4_slides_lead.pptx
     February 02, 2006 - When emergencies have occurred at these events in the past, many people come running and there is general … skills Designed to improve outcomes An accurate recounting of key events Analysis of why the event occurred

117. Appendix A. Recommendations for Ideal Consumer Reporting Systems (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/hotline/hotline-appendixa.pdf
     May 11, 2016 - The system 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

118. Appendix A. Recommendations for Ideal Consumer Reporting Systems | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/hotline/appa.html
     May 01, 2016 - The system 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

119. Premortem Tool | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/modules/cusp/premortem-tool.html
     January 01, 2017 - "Spend the next 10 minutes writing down all the reasons you believe this failure occurred. … Please spend the next 10 minutes writing down all the reasons you believe this failure occurred.

120. Tool: Premortem (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/premortem-tool.docx
     January 01, 2017 - · “Spend the next 10 minutes writing down all the reasons you believe this failure occurred. … Please spend the next 10 minutes writing down all the reasons you believe this failure occurred.