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Showing results for "occurred".
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www.ahrq.gov/teamstepps-program/curriculum/situation/tools/star.htmlJuly 01, 2024 - members are asked to respond to a change in a patient's status when expected improvements have not occurred
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4/module4-event-reporting-investigation-analysis.pptxSeptember 10, 2015 - information, other than event reports, that might provide information indicating that a CANDOR event has occurred … create a cohesive environment for informing the organization as to whether a CANDOR event may have occurred … implement the best practice of creating a hotline for staff to call when they feel a CANDOR event has occurred … Risk Management can also provide ongoing support to managers on the unit(s) where the event occurred. … Also, the location where the event occurred is generally no longer intact, so information that could
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www.ahrq.gov/hai/tools/surgery/modules/sustainability/learn-from-defects-fac-notes.htmlDecember 01, 2017 - Ask: What if the same situation occurred on a different shift? … Say: When a defect has already occurred, ask your frontline staff. … Ask: How do all these pieces lead to this error or the event that occurred? … If you can, simulate the defect, particularly for a defect that has occurred. … Say: If a contributing factor is a major reason why the defect occurred, place that factor in the top
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_learn_from_defects_facnotes.docxDecember 01, 2017 - ASK: What if the same situation occurred on a different shift? … SAY: When a defect has already occurred, ask your frontline staff. … ASK: How do all these pieces lead to this error or the event that occurred? … If you can, simulate the defect, particularly for a defect that has occurred. … SAY: If a contributing factor is a major reason why the defect occurred, place that factor in the top
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www.ahrq.gov/news/newsletters/e-newsletter/688.htmlNovember 01, 2019 - included fear of missing an infection and being uncertain of a diagnosis, though these reasons often occurred … Insufficient progress has occurred, the authors asserted, since a 2015 National Academies of Sciences
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www.ahrq.gov/patient-safety/settings/hospital/candor/grand-rounds.htmlAugust 01, 2022 - remember what patients want in our communication with them: An explicit statement that an error occurred … The Investigation: to determine how the event occurred, and how to mitigate that event or even prevent … This is a cornerstone of the CANDOR process of investigating the root cause of how an error occurred, … disclosure is a process , and the first step is to: Let the patient and family know an adverse event occurred … a result of the investigation and analysis of Michelle’s case, the following patient safety changes occurred
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallpxreports-ig.pdfNovember 09, 2017 - The new contributing risk factor elements represent changes that occurred in a resident’s clinical … It displays the number of falls that occurred and the risk factors associated with the falls. … For each of the months (1 or 3) included in the report, any fall that occurred before the report date … For each of the months (1 or 3) included in the report, any fall that occurred before the report date … , Shift during which the fall occurred, Time at which the fall occurred, The location of
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www.ahrq.gov/patient-safety/reports/issue-briefs/education-dx-outcomes-1.htmlMarch 01, 2022 - amount, content, and quality within and across professions. 10 - 12 Much learning about diagnosis has occurred
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/education-dx-outcomes-1.htmlMarch 01, 2022 - amount, content, and quality within and across professions. 10 - 12 Much learning about diagnosis has occurred
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/best-practices/respiratory-slides.pptxNovember 01, 2019 - Treat as community-acquired pneumonia if the event occurred within 72 hours of admission to a healthcare … Treat as healthcare-associated pneumonia if the event occurred after 72 hours of admission to a healthcare … antibiotics without improvement within 48 hours: Treat as community-acquired pneumonia if the event occurred … Treat as healthcare-associated pneumonia if the event occurred after 72 hours of admission to a health
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www.ahrq.gov/sites/default/files/2024-05/sarcevic-report.pdfJanuary 01, 2024 - “Now” activations occurred in 9% of digital checklist cases. … False checks occurred for 29 of the 32 tasks and accounted for 16% of all checked items. … Of all true-checks, 15% occurred before the team started performing a task. … Sixteen percent of all true checks occurred as the corresponding tasks were being performed. … Post-check occurred when the check-off timestamp occurred after the end time of the corresponding task
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www.ahrq.gov/news/newsroom/case-studies/201516.htmlJune 01, 2015 - The training occurred at the medical and pharmacy schools at the University of California, San Diego
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module7/exsummary.pdfMarch 20, 2014 - Identify the instances where a breakdown in teamwork has occurred as it relates to the specific teamwork
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Does Medical Error Disclosure Violate the Medical Malpractice Insurance Cooperation Clause? (pdf file)
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Banja.pdfJanuary 01, 2004 - medical error, which is morally required of physicians when they know that a harm-causing error has occurred … ethically required to inform the patient of all the facts necessary to ensure understanding of what has occurred … Jones, an error occurred in your care that was responsible for the harm you experienced, and we apologize … An example of this occurred in Royston Moore v. … health professionals to desist from admitting liability when they know that harm-causing error has occurred -
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_learn_from_defects.pptxDecember 01, 2017 - ASK: What if the same situation occurred on a different shift? … SAY: When a defect has already occurred, ask your frontline staff. … ASK: How do all these pieces lead to this error or the event that occurred? … If you can, simulate the defect, particularly for a defect that has occurred. … What actions occurred? What were care team members thinking and feeling?
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www.ahrq.gov/sites/default/files/2024-01/shenep-report.pdfJanuary 01, 2024 - Current controls almost always detect the failure. 2 Very slight effect Actual error occurred … Good likelihood that current controls will detect. 4 Minor effect Actual error occurred. … Review effectiveness of 80%. 5 Moderate effect Actual error occurred and reached the patient … Review effectiveness of 50%. 7 Major effect Actual error occurred and reached the patient. … Page 8 8 Extreme effect/major injury Actual error occurred and reached the patient.
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www.ahrq.gov/patient-safety/about/challenge-competition.htmlFebruary 01, 2024 - The most visible advances occurred in the services and nursing units (a 50% reduction in general surgery
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www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-1.htmlJune 01, 2023 - persist for many years, elicitation techniques must inquire about the impact of adverse events that occurred
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-1.htmlJune 01, 2023 - persist for many years, elicitation techniques must inquire about the impact of adverse events that occurred
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mod3.htmlMarch 01, 2019 - Objectives Session 1 Introduction A Safe and Enjoyable Environment Knowing When a Fall Has Occurred
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