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Showing results for "occurred".
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Mod01-Grand-Rounds-Slides (pdf file)
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/grandrounds/mod01-grand-rounds-slides.pdfApril 01, 2016 - An explicit statement that an error occurred. 2. … 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 … result of the investigation and analysis of Michelle’s case, the following patient safety changes occurred -
www.ahrq.gov/news/newsletters/e-newsletter/index.html?order=field_date_created&page=3&sort=ascJanuary 16, 2024 - AHRQ Accelerates Efforts To Advance Health Equity April 9, 2024 Surge in Drug Shortages Occurred
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www.ahrq.gov/teamstepps/instructor/fundamentals/module7/exsummary.htmlMarch 01, 2014 - Identify the instances where a breakdown in teamwork has occurred as it relates to the specific teamwork
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www.ahrq.gov/hai/cusp/toolkit/content-calls/index.htmlSeptember 01, 2013 - Nationwide Implementation of the Comprehensive Unit-based Safety Program (CUSP) These webinars occurred
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/ereportguide.htmlSeptember 01, 2017 - If no ED visits occurred in the past 90 days, the field is blank. ED Discharge Diagnosis. … If no hospitalizations have occurred in the past 90 days, the field is blank. … If no hospitalization occurred in the past 90 days, the cell is blank. … This is the number of observation stays that occurred during the month. Observation Stay Rate. … This is the number of ED visits that occurred during the month. ED Visit Rate.
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On-Time Falls Prevention: Electronic Reports (pdf file)
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallpxsamplereports.pdfNovember 06, 2017 - within the facility’s electronic medical record, such as nurse assessments, and represent changes that occurred … facility’s electronic medical record as determined by the facility and may represent changes that occurred … Summary of Fall Risk Factors Report is a count of risk factors associated with the falls that have occurred … For each month, it displays the number of falls that occurred and the risk factors associated with … , • Shift during which the fall occurred, • Time at which the fall occurred, • The location of the -
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/module1-overview.pptxMay 19, 2016 - understand what a CANDOR event is and what to do when they recognize that a CANDOR event is occurring or has occurred … Activity: List de-identified events that have occurred in your organization. … Once activated, the CANDOR Response Team will work with the caregivers where the event occurred to ensure
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www.ahrq.gov/sites/default/files/2024-11/blumenthal-report.pdfJanuary 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
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www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/webinars/perinatal-care-experience-slides.pdfMarch 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
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/grand-rounds-presentation-slides.pptxJanuary 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
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www.ahrq.gov/teamstepps-program/curriculum/team/tools/debrief.htmlDecember 01, 2023 - Analysis of why the event occurred, what worked, and what did not work.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Jones_91.pdfJuly 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
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Dear [NURSES NAMES]-- (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/clabsitools/clabsitoolsap8.docDecember 11, 2012 - Because the event occurred more than 48 hours from the time of line insertion, it is clear that this -
Dear [NURSES NAMES]-- (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/clabsitools/clabsitoolsap9.docDecember 11, 2012 - Because the event occurred more than 48 hours from the time of line insertion, it is clear that this -
www.ahrq.gov/hai/cusp/toolkit/index.htmlJuly 01, 2018 - the Nationwide Implementation of the Comprehensive Unit-based Safety Program (CUSP) These webinars occurred
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-November_45.pdfJanuary 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
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/14295%20Shenep-draft-1.pdfJune 01, 2005 - 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/sites/default/files/2024-04/eskandari-raval-report.pdfJanuary 01, 2024 - Of six Illinois medical centers, 123 VTE events occurred; 37.5% occurred after discharge.
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TeamSTEPPS Specialty Scenarios: Dental (pdf file)
www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/scenarios/dental.pdfMarch 19, 2014 - In this scenario, either of two actions should have occurred. … Had a brief or check-back occurred, they would have shared their individual situation awareness with -
www.ahrq.gov/teamstepps/instructor/scenarios/dental.htmlMarch 01, 2014 - In this scenario, either of two actions should have occurred. … Had a brief or check-back occurred, they would have shared their individual situation awareness with
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