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Total Results: 2,959 records

Showing results for "occurred".

121. Executive Summary | Agency for Healthcare Research and Quality
     www.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

122. Factors that Impact Perinatal Care Experience and Outcomes: Slide Presentation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/webinars/perinatal-care-experience-slides.pdf
     March 06, 2025 - design to understand the association between (1) the change in Medicaid eligibility thresholds that occurred … design to understand the association between (1) the change in Medicaid eligibility thresholds that occurred … a promising sign that improvements in access to needed primary and specialist care may have also occurred

123. Final Progress Report: Validation of an Innovative Approach to Error Reduction (pdf file)
     www.ahrq.gov/sites/default/files/2024-11/blumenthal-report.pdf
     January 01, 2024 - experience generally; however, their work revealed that 2.9% of adverse events in hospitalized patients occurred … adverse events were detected through reviewing charts of hospitalized patients, problems that might have occurred … Chart Review The chart review identified the prevalence and characteristics of errors that occurred in … We therefore have some data on charts in which no relocation procedure occurred or no sedative or anesthetic … The hospital discharge summary allowed chart abstractors to identify adverse events that may have occurred

124. The Association Between Pharmacist Support and Voluntary Reporting of Medication Errors: An Analysis of MEDMARX® Data (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Jones_91.pdf
     July 17, 2008 - but it did not reach the patient 14.9 23.9 40.9 C Error occurred that reached the patient but did … not cause harm 53.6 49.8 43.4 D Error occurred that reached the patient and required monitoring to … that might have contributed to or resulted in permanent patient harm 0.0 0.0 0.0 H Error occurred … that required intervention necessary to sustain life 0.0 0.0 0.0 I Error occurred that … We do believe, however, that it is unlikely that misclassifications of errors occurred to an extent

125. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/grand-rounds-presentation-slides.pptx
     January 01, 2014 - to 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, … “Don’t tell me you were sorry that the problem occurred. … disclosure is a process, and the first step is to: Let the patient and family know an adverse event occurred

126. Physician-Reported Adverse Events and Medical Errors in Obstetrics and Gynecology (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-November_45.pdf
     January 01, 2007 - House officers were encouraged to fill out cards immediately after reportable events occurred and to … following definitions were used to code the type of event: • Adverse events were injuries that occurred … • Potential adverse events were errors where injuries could have occurred but did not, either due … For example, quality problems (other than AEs and potential AEs) occurred when appropriate instruments … alternatively, might have generated a greater number of reports, since more potential events could have occurred

127. Content Calls for the Nationwide Implementation of the Comprehensive Unit-based Safety Program (CUSP) | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/toolkit/content-calls/index.html
     September 01, 2013 - Nationwide Implementation of the Comprehensive Unit-based Safety Program (CUSP) These webinars occurred

128. PowerPoint Presentation: Learn From Defects Through Sensemaking
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects.pptx
     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. 13 What Happened? … What actions occurred? What were care team members thinking and feeling?

129. Rates | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/clabsi-neonatal/nclabsi5.html
     January 01, 2013 - baseline, a neonatal central line-associated bloodstream infection (NCLABSI) rate reduction of 46 percent occurred

130. Final Progress Report: Illinois Surgical Quality Improvement Collaboration Conference: Venous Thromboembolism (pdf file)
     www.ahrq.gov/sites/default/files/2024-04/eskandari-raval-report.pdf
     January 01, 2024 - Of six Illinois medical centers, 123 VTE events occurred; 37.5% occurred after discharge.

131. Final Progress Report: Unexpected Clinical Events: Impact on Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-12/weinger2-report.pdf
     January 01, 2024 - The patient was affected in 78% of NRE (36% of all cases), and patient injury occurred in 19% of NRE … A popular method is to examine adverse events that have occurred and “trace back” to attempt to pinpoint … More than one NRE occurred in 23% (32/139) of the NRE-containing cases, to yield a total of 187 NRE; … 5% occurred preoperatively, 34% of NRE occurred during induction, 45% were during maintenance, 13% … were during emergence, and 3% occurred postoperatively.

132. Reviewing the Team's Performance: Debrief | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps-program/curriculum/team/tools/debrief.html
     December 01, 2023 - Analysis of why the event occurred, what worked, and what did not work.

133. Interim Update on 2013 Annual Hospital-Acquired Condition Rate (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/interimhacrate2013_0.pdf
     October 27, 2014 - hospital patients over the 3 years (2011, 2012, 2013) relative to the number of HACs that would have occurred … precise causes of the decline in patient harm are not fully understood, the increase in safety has occurred … whether any of 21 types of adverse events—such as adverse drug events, falls, and pressure ulcers—occurred … in 2013 than would have occurred if the rate of HACs had remained steady at the 2010 level (Exhibit … The majority of deaths averted occurred as a result of reductions in the rates of pressure ulcers 15

134. Establishing a Program of In Situ Simulations: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/situ/simulation-fac-guide.html
     July 01, 2023 - Scenarios for Simulation Say: In situ simulations can be designed to replay real events that have occurred … Team members share their perspectives on what occurred during the scenario and reach common ground. … Video review is extremely helpful in allowing the participants to see exactly what communication occurred … simulation also participate in the debriefing to provide a patient/caregiver perspective on the events that occurred

135. Best Practices in the Diagnosis and Treatment of Community-Associated Lower Respiratory Tract Conditions (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/best-practices/respiratory-facilitator-guide.pdf
     November 01, 2019 - Treat as community-acquired pneumonia if the event occurred within 72 hours of admission to a healthcare … healthcare-associated pneumonia with agents like cefepime or piperacillin/tazobactam if the event occurred … antibiotics without improvement within 48 hours: Treat as community- acquired pneumonia if the event occurred … Treat as healthcare-associated pneumonia if the event occurred 72 hours or more after admission to a

136. How to Use the CUSP Toolkit | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/toolkit/index.html
     July 01, 2018 - the Nationwide Implementation of the Comprehensive Unit-based Safety Program (CUSP) These webinars occurred

137. Final Progress Report: Evaluate the Effects of the Massachusetts Reporting System (pdf file)
     www.ahrq.gov/sites/default/files/2024-11/ridley-report.pdf
     January 01, 2024 - Structured data included the date the incident occurred, the number of involved patients, the patient … Enrollment was tracked, and follow-up with hospital CEOs occurred through direct email communication … These huddles were initiated early in the project and occurred consistently throughout. … Ninety-seven percent of respondents believe the hospital where the incident occurred should be the source … Reviewers had to confirm that the patient’s medical chart reflected that an AE occurred.

138. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/ereports.html
     September 01, 2017 - This section displays the number of ED visits that occurred in the following timeframes:  0-7 days … This section displays the number of hospitalizations that occurred in the following timeframes: 0 … from multiple data sources within the facility’s electronic medical record and represent changes that occurred … potential root causes (e.g., treatment unavailable at facility, treatments prior to transfer) that occurred … if the visits were for potentially preventable conditions, the time of day/day of week the transfers occurred

139. Harborview Medical Center Uses AHRQ’s Quality Indicators To Improve Patient Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/202504.html
     June 01, 2025 - They tailored their system to report on all blood clots that occurred at the hospital. 

140. Section 1: Overview of Mutual Support Key Concepts and Tools | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps-program/curriculum/mutual/overview/index.html
     July 01, 2023 - Timely— given soon after the target behavior has occurred.