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Total Results: 2,792 records

Showing results for "occurred".

141. Adverse Events Among In-Hospital Medicare Patients in 2021 and 2022 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/quality-measures/qsrs/qsrs-2021-2023-adverse-event-data-report.pdf
     January 01, 2023 - , the QSRS was used to conduct the underlying chart abstractions to determine whether specific AEs occurred … Algorithms are coded into QSRS that use abstractors’ responses to identify whether an AE occurred during … In other words, the QSRS may show that several different AEs occurred during a single hospital stay … showed that in 7.1 percent of the sampled records from Medicare patients in 2021, at least one AE occurred … Device Stay during which one or more occurrences associated with the use of a device Occurred 5.

142. California Hospital Reduced Infections, Improved Diabetes Care with AHRQ Safety Program | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/201807.html
     November 01, 2018 - telemetry nurses and found that distractions such as phone calls and patients pressing call buttons occurred

143. Nebraska Critical Access Hospitals Improve Safety With AHRQ TeamSTEPPS® | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/ktcquips52.html
     October 01, 2014 - The largest increases of 5 percent and 6 percent occurred in "manager actions promoting patient safety

144. Two Indiana Facilities Use AHRQ Toolkit to Revise Medication Reconciliation | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/ktcquips91.html
     October 01, 2014 - responsibility for completing medication reconciliation to the ICU charge nurse to eliminate the confusion that occurred

145. Using Six Sigma® Methodology to Improve Handoff Communication in High-Risk Patients (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Mistry_114.pdf
     May 05, 2008 - Define,” “Measure,” and “Analyze” steps of the Six Sigma framework—communication errors frequently occurred … centered on establishing a team handoff model and modifying the environment in which the handoffs occurred … Specifically, only patient-specific conversation or urgent clinical interruptions occurred during the … overcome a time-consuming procedure.27 Furthermore, errors in the use of aviation checklists most often occurred … Conclusion We found that communication delays commonly occurred during the handoff process of patients

146. Chapter 3. Development of the Data Infrastructure | Agency for Healthcare Research and Quality
     www.ahrq.gov/practiceimprovement/delivery-initiative/ihs/chapter3.html
     December 01, 2017 - The identified differences were minimal and were primarily due to registration updates that occurred … Admissions that occurred within 30 days of a previous inpatient discharge were identified as readmissions … Diabetes education visits are visits that occurred in diabetes education clinics and are not counted

147. Introduction to Diagnostic Errors | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-cognitive-load1.html
     May 01, 2024 - identification of inaccurate diagnostic reasoning and diagnostic error often takes place after the error has occurred

148. AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/6.html
     December 01, 2017 - incontinence at their facility (see details in the table below): Number of shifts incontinent episodes occurred … Worsening Ulcer Wound Assessment If wound assessment occurred in last 7 days and prior to report

149. Project Report - Lean Sigma
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/implement/teamwork.pptx
     January 01, 2007 - Events3 Root causes of infection-associated events (2005) 7 Exercise Think of a defect that has occurred … offered 23 As seen in TeamSTEPPS® Feedback1 Timely—given soon after the target behavior has occurred

150. Silence A Commentary | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/liability/silence.html
     August 01, 2017 - There are four things patients and families want after medical harm has occurred: tell us what happened … after medical harm. 5 I believe there is a fifth desire for some patients and families after harm has occurred

151. Sensemaking and Learn From Defects for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-fac-guide.html
     July 01, 2023 - the event or issue by providing teams the tools and resources needed to make sense of a failure that occurred … We then ask why this consequence occurred. … Try to view the world as they did when the event occurred. Why did it happen? Step 1.

152. Learning-From-Antibiotic-Adverse (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/learning-from-antibiotic-adverse.docx
     June 01, 2021 - X Team Factors Example: Team discussion about need to start antibiotics occurred

153. CAUTI Learning From Defects Tool (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cauti-learning-from-defects-revised.docx
     April 01, 2022 - (Communication Plan) Now that you have more information about how and why this CAUTI occurred, how will

154. CLABSI Learning From Defects Tool (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/clabsi-learning-from-defects_revised.docx
     April 01, 2022 - (Communication Plan) Now that you have more information about how and why this CLABSI occurred, how will

155. Describe How a Plan or Provider Can Influence a Quality Measure | Agency for Healthcare Research and Quality
     www.ahrq.gov/talkingquality/translate/labels/describe.html
     January 01, 2023 - would almost always be placed by a doctor, so the nurse should not be held accountable if an infection occurred

156. Injection Safety/Safe Medication Handling (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/esrd/injectionsafety.pdf
     January 03, 2014 - These outbreaks occurred in outpatient settings such as doctor’s offices, outpatient clinics, dialysis

157. New AHRQ SOPS™ Health Information Technology Patient Safety Supplemental Items for Hospitals - Optimizing (Gandhi) (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospital/healthitwebinar/sops-hit-webcast3-gandhi.pdf
     January 01, 2018 - Prevent errors and adverse events • Facilitating a more rapid response after an adverse event has occurred

158. Exhibit 4.2. Suntown Hospital | Agency for Healthcare Research and Quality
     www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit4-2.html
     November 01, 2014 - study of Suntown Hospital, which included 28 interviews with staff of all levels of the organization, occurred

159. Los Angeles County Health Center Uses CAHPS To Shorten Wait Times | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/201718.html
     April 01, 2018 - Responses to the CAHPS survey indicated that long wait times occurred frequently.

160. UChicago Medicine Reduces Perioperative Venous Thromboembolism with AHRQ's Toolkit | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/about/uni-chicago-medicine.html
     February 01, 2024 - institution when comparing calendar year January–July 2022 to January–July 2023, the most visible advances occurred