Results

Total Results: 2,790 records

Showing results for "occurred".

1401. Applying a Novel Organization Change Scale in a Multisite Patient Safety Initiative | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/liability/brock.html
      August 01, 2017 - Advances in Patient Safety and Medical Liability Applying a Novel Organization Change Scale in a Multisite Patient Safety Initiative Previous Page Next Page Table of Contents Advances in Patient Safety and Medical Liability Preface Acknowledgments Prologue Silence A Commentary Reforming th…

1402. Two-Day Training Content | Agency for Healthcare Research and Quality
      www.ahrq.gov/teamstepps-program/curriculum/intro/teach/two-day.html
      January 01, 2024 - a story, either in small groups or as a class, ask them to discuss: What breakdowns in teamwork occurred

1403. Re-engineering the Hospital Discharge: An Example of a Multifaceted Process Evaluation (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Anthony.pdf
      January 01, 2005 - means of reducing them, root cause analysis provides indepth insight into errors that have actually occurred—in … technique is used reactively, to probe the reason for a bad outcome or for problems that have already occurred

1404. Chapter 2. Analyze Care Delivery | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/vtguide/guide2.html
      February 01, 2016 - Preventing Hospital-Associated Venous Thromboembolism Chapter 2. Analyze Care Delivery Previous Page Next Page Table of Contents Preventing Hospital-Associated Venous Thromboembolism Preface Executive Summary Chapter 1. The Framework for Improvement Chapter 2. Analyze Care Delivery Chapter…

1405. Chapter 2. Analyze Care Delivery | Agency for Healthcare Research and Quality
      www.ahrq.gov/es/patient-safety/settings/hospital/vtguide/guide2.html
      February 01, 2016 - Preventing Hospital-Associated Venous Thromboembolism Chapter 2. Analyze Care Delivery Previous Page Next Page Table of Contents Preventing Hospital-Associated Venous Thromboembolism Preface Executive Summary Chapter 1. The Framework for Improvement Chapter 2. Analyze Care Delivery Chapter…

1406. Selected Best Practices and Suggestions for Improvement (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d4i_pdi11-dehiscence-bestpractices.pdf
      May 17, 2016 - Selected Best Practices and Suggestions for Improvement Pediatric Toolkit for Using the AHRQ Quality Indicators How To Improve Hospital Quality and Safety 1 Tool D.4i Selected Best Practices and Suggestions for Improvement PDI 11: Postoperative Wound Dehiscence Why focus on postoperative wound dehiscence in…

1407. Selected Best Practices and Suggestions for Improvement (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4w_combo_pdi11-dehiscence-bestpractices.pdf
      May 17, 2016 - Selected Best Practices and Suggestions for Improvement Toolkit for Using the AHRQ Quality Indicators How To Improve Hospital Quality and Safety 1 Tool D.4w Selected Best Practices and Suggestions for Improvement PDI 11: Postoperative Wound Dehiscence Why focus on postoperative wound dehiscence in children?…

1408. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/science-of-safety-facguide.docx
      January 01, 2017 - reporting systems, sentinel events, and claims data are reactive—the unfortunate event has already occurred

1409. Action-Plan-Template (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/action-plan-template.docx
      April 01, 2022 - Unit Action Plan The Comprehensive Unit-based Safety Program (CUSP) or healthcare-associated infection (HAI) leader is responsible for leading the CUSP team in completing an Action Plan in order to drive work related to lowering bloodstream infections (CLABSI) and/or catheter-associated urinary tract infections (CAUTI)…

1410. Improving Error Reporting in Ambulatory Pediatrics with a Team Approach (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Neuspiel_43.pdf
      March 05, 2008 - pediatric emergency department in Canada, 100 prescribing errors and 39 medication administration errors occurred

1411. Improving Patient Safety in Long-Term Care Facilities, Module 3 (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/ltcmodule3.pdf
      June 01, 2012 - Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Knowing When a Fall Has Occurred … Knowing When a Fall Has Occurred A person can end up on the ground for many reasons.

1412. 26,000 Close Call Reports: Lessons from the University of Texas Close Call Reporting System (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Simmons_66.pdf
      April 03, 2008 - that explain why employees may not report errors: (1) fear, (2) disagreement over whether an error occurred … Also, because historically reports were submitted only when an actual error had occurred, a “change

1413. Enabling Real-Time Identification of Burnout Risk Among Clinicians in Primary Care Practices (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/about/impact-stories/enabling-real-time.pdf
      January 01, 2023 - Enabling Real-Time Identification of Burnout Risk Among Clinicians in Primary Care Practices Enabling Real-Time Identification of Burnout Risk Among Clinicians in Primary Care Practices AHRQ Impact: Researchers have developed a prediction tool to identify primary care practices at high-risk of clinician burnout…

1414. PowerPoint Presentation
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/esrd/creating-safety-culture/cultureofsafety_hemodialysis.pptx
      September 03, 2014 - In determining what defect occurred, teams reconstruct the timeline of the event by placing themselves … well as offering help to their peers.     42 Feedback Timely—give soon after the target behavior has occurred … promote a supportive climate, feedback must be:   Timely, and given soon after the target behavior has occurred … Try to view the world as they did when the event occurred.   Why did it happen? Step 1.

1415. Department of Veterans Affairs Emergency Airway Management Initiative (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Stalhandske_71.pdf
      February 23, 2008 - These claims included some cases that occurred within the operating room. … Our database was unable to differentiate those that occurred due only to emergency airway management.b

1416. Module 1: Using the Comprehensive Long-Term Care Safety Modules: Applying Safety Principles: Facilitator Notes | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module1/mod1-facguide.html
      March 01, 2017 - When reckless behavior has occurred, it must be met with remedial or punitive action to decrease or eliminate

1417. On-Time Pressure Ulcer Healing: Facilitator Training Instructor's Guide | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/guide.html
      December 01, 2017 - high risk or had a recent change in risk, would we do things differently to intervene before the event occurred

1418. Nursing Practice Guide (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/nursing-protocols/nursing-practice-guide.docx
      March 01, 2022 - Nursing Practice Guide Section 9-5 – Decolonization of Non-ICU Patients With Devices Nursing Practice Guide Use this guide to help ensure that all nursing practice processes and leadership support are in place to actively support the decolonization intervention. Engagement and Collaboration CHG Bath Documentation N…

1419. Nursing Practice Guide (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/nursing-protocols/nursing-practice-guide.pdf
      March 01, 2022 - Nursing Practice Guide AHRQ Pub. No. 20(22)-0036 March 2022 Section 9-5 – Decolonization of Non-ICU Patients With Devices Nursing Practice Guide Use this guide to help ensure that all nursing practice processes and leadership support are in place to actively support the decolonization intervention. CHG = c…

1420. FAQs (Staff): Safety and Side Effects: CHG and Mupirocin (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/faqs/faq-safety-chg-mupirocin.docx
      March 01, 2022 - FAQs (Staff): Safety and Side Effects: CHG and Mupirocin Decolonization of Non-ICU Patients With Devices Section 14-6 – Addressing Questions Asked by Staff: Safety and Side Effects of Chlorhexidine and Mupirocin This hospital will be using chlorhexidine gluconate (CHG) and nasal mupirocin to reduce bacteria that c…