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Total Results: 4,281 records

Showing results for "occurred".

181. Appendix C: Using Solid Analytical Methods to Estimate Program Impacts | Agency for Healthcare Research and Quality
     www.ahrq.gov/ncepcr/tools/pcmh/implement/appendix-c.html
     September 01, 2021 - outcomes before the intervention would have persisted after the intervention if the intervention had not occurred

182. Dashboard Information | Agency for Healthcare Research and Quality
     www.ahrq.gov/npsd/data/dashboard/info.html
     June 01, 2019 - incorrect medication to take and the patient recognizes it as such and refuses to take it, an incident has occurred

183. A Visual Computer Interface Concept for Making Error Reporting Useful at the Point of Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Singh_69.pdf
     April 04, 2008 - adjustment; this can be entered in the same fashion. 8 From the list, select the Error that occurred … Lab Phone/Fax Chart StorySeverity Click Here (this is where the error occurred) 1 2 Contributing … factors for Error: Wrong dose Click on the place where a Contributor occurred Cascade Consequences … Lab Phone/Fax Chart Consequences of Error: Wrong dose Click on the place where a Consequence occurred … StorySeverity Click here (where th conseque occurred) e nce StorySeverity G and R Singh 2001 Cascade

184. Methodological Challenges in Describing Medication Dosing Errors in Children (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/McPhillips.pdf
     January 01, 2004 - events in hospitalized patients.1, 7 In one adult study, half of all preventable adverse drug events occurred … medication dosing errors were the most common type of medication prescribing error, and these errors occurred … pharmacy-based review of medication orders in two pediatric hospitals, Folli et al.9 found that errors occurred … In the most comprehensive study involving pediatric patients, medication errors occurred in nearly … all medication orders.7 Serious medication errors, those in which harm to the patient was possible, occurred

185. Facilitating Transformational Change in Primary Care | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/blog/ahrqviews/change-primary-care.html
     August 01, 2019 - Innovations that have occurred in recent years -- growth of the patient-centered medical home model,

186. Final Progress Report: Mortality Assessment in Lung Cancer Resection (pdf file)
     www.ahrq.gov/sites/default/files/2024-11/kowozer-report.pdf
     January 01, 2024 - Composite major morbidity or mortality occurred in 1,612 patients (8.6%). … Composite major morbidity or mortality occurred in 1,612 patients (8.6%). … The majority of his research development has occurred during weekly meetings with his primary mentor

187. Learning from Errors in Ambulatory Pediatrics (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Mohr.pdf
     February 01, 2004 - children.3 Of the errors observed by family physicians in their own practice settings, 17.5 percent occurred … Pediatricians were then asked to use the tool to report all errors that occurred in a 1-month period … Participants were asked to report each error that occurred during the study data collection period that … Reported errors occurred most commonly in the domains of preventive screening and immunization and of … Reported errors occurred most frequently in the domains of preventive screening and immunization, and

188. 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

189. 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

190. Head of Bed Elevation or Semirecumbent Positioning Literature Review | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/modules/technical/head-bed-elevation-lit-review.html
     January 01, 2017 - VAP occurred in 43 patients (15.5%). … VAP occurred more often in cardiothoracic patients (21.6%) compared with medical patients (9.3%) (p=0.03 … VAP occurred in 43 patients (15.5%). … VAP occurred more often in cardiothoracic patients (21.6%) compared with medical patients (9.3%) (p=0.03

191. Tool: SSA (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/head-bed-elevation-litreview.docx
     January 01, 2017 - VAP occurred in 43 patients (15.5%). … VAP occurred more often in cardiothoracic patients (21.6%) compared with medical patients (9.3%) (p=0.03 … VAP occurred in 43 patients (15.5%). … VAP occurred more often in cardiothoracic patients (21.6%) compared with medical patients (9.3%) (p=0.03

192. Section 8: The Care Management Evidence Base (continued) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/medicaidmgmt/mm8a.html
     October 01, 2014 - quality of life improved significantly at 6 months, whereas at 12 months, no significant improvement occurred … symptoms were reduced significantly, but at 12 months, no significant change in asthma symptoms had occurred … Similarly, the same study found that after 2 weeks, no differences occurred in asthma planning visits … same study found that after two weeks, no differences in asthma planning visits or acute care visits occurred

193. Simulation Facguide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/situ/simulation_facguide.docx
     May 01, 2017 - Slide 6 SAY: In situ simulations can be designed to replay real events that have occurred on a unit … 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

194. 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

195. Guides and Resources for Operationalizing Your MRSA and SSI Prevention Program | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mrsa-prevention/surgery/operationalizing-prevention-program.html
     April 01, 2025 - Investigation Tool is a helpful tool to help to investigate why a surgical site infection may have occurred

196. CAUTI Event Reporting Tool (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/clabsi-event-reporting.docx
     April 01, 2022 - central lines in each nursing unit where this patient received care for the month in which the CLABSI occurred … rates for hand hygiene in each unit where this patient received care for the month in which the CLABSI occurred … line maintenance bundle for each unit on which the patient received care during the month the CLABSI occurred … variations happening on any of the units where the patient was located during the month in which the CLABSI occurred

197. CAUTI Event Reporting Tool (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/clabsi-event-reporting_revised.docx
     April 01, 2022 - central lines in each nursing unit where this patient received care for the month in which the CLABSI occurred … rates for hand hygiene in each unit where this patient received care for the month in which the CLABSI occurred … line maintenance bundle for each unit on which the patient received care during the month the CLABSI occurred … variations happening on any of the units where the patient was located during the month in which the CLABSI occurred

198. 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.

199. Learning From Defects Through Sensemaking: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-slides.html
     December 01, 2017 - What actions occurred? What were care team members thinking and feeling? … Y-axis begins with "minor reason why defect occurred" and moves to "major reason why defect occurred.

200. Final Progress Report: Reducing Harm to Patients from Diagnostic Errors (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/berner-report.pdf
     January 01, 2025 - In addition, attendees submitted abstracts for the poster session, which occurred during the first … Graber, occurred in October 2009, and the proceedings were provided to those attendees.