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Showing results for "occurred".
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www.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-slides.htmlDecember 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.
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Table 5.A.1. Evidence Table (pdf file)
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-143-section-5a-evidence-table.pdfJanuary 01, 2014 - Medical records flagged with an alert were reviewed to determine whether an ADE had occurred. … Whenever a trigger occurred, the data management system automatically sent an alert, leading reviewers … The majority of AEs occurred in the neonatal intensive care unit (13.4 AEs per 1000 patient-days; … , and if it had occurred, the event’s preventability and severity. … Chart reviews occurred in a 2-stage process. -
www.ahrq.gov/patient-safety/resources/simulation-issue-brief3.htmlJuly 01, 2024 - Simulation That Revealed an Equipment Malfunction A patient safety event occurred when an infusion delivered
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/b1_pdi_applyingpdis.pdfMarch 01, 2016 - population for that specific indicator Observed events = for each PDI, the total sum of events that occurred … observed rate (also called the raw rate) is the actual rate at which events measured by the indicator occurred … probability that a particular indicator event will occur based on the frequency with which the event occurred … (Note that a lower rate for a PDI signifies better performance because fewer adverse events have occurred
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/b1_combo_applyingqis.pdfMarch 01, 2016 - for that specific indicator Observed events = for each QI indicator, the total sum of events that occurred … observed rate (also called the raw rate) is the actual rate at which events measured by the indicator occurred … probability that a particular indicator event will occur based on the frequency with which the event occurred … (Note that a lower rate for a PSI signifies better performance because fewer adverse events have occurred
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/situ/simulation_facguide.pdfMay 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 … also participate in the debriefing to provide a patient/caregiver perspective on the events that occurred
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mod1sess1.htmlOctober 01, 2014 - See if a change occurred in any of the resident's vital signs—blood pressure, pulse rate, breathing rate … See if a change occurred in any other resident's vital signs.
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/3.htmlDecember 01, 2017 - Weights are calculated in two ways: Point-to-Point: using two data points to determine if weight loss occurred … A date next to a weight loss value indicates the date the weight change occurred. 3.3.4.4.
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man3.htmlDecember 01, 2017 - The nurse will write in the resident's name, medical record number, date the incident occurred and time … If the resident slipped, the nurse should specify how this occurred.
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www.ahrq.gov/news/newsroom/case-studies/201809.htmlJanuary 01, 2019 - use of an indwelling catheter is considered appropriate and consider whether an infection may have occurred
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/intro.htmlNovember 01, 2017 - the facility team with information to assist them in analyzing resident fall risks, falls that have occurred
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www.ahrq.gov/news/newsroom/case-studies/201708.htmlMay 01, 2017 - Of 2,064 crisis intervention-related incidents that occurred from January through November 2016 in the
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www.ahrq.gov/news/newsroom/case-studies/ktcquips82.htmlOctober 01, 2014 - By creating a flowchart of the medication reconciliation process that occurred from hospital discharge
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2023-nhqdr-es.pdfJanuary 01, 2023 - ■ The change in racial and ethnic diversity has occurred largely in younger age groups. … The slowdown occurred after passage of several federal COVID-19-related bills, which included temporary … This was due, in part, to the emergence of more transmissible variants of the virus, which occurred … • Most COVID-19 deaths occurred among adults age 65 and over. … But large numbers of deaths also occurred among adults ages 50-64 and 18-49, especially during surges
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2023-nhqdr-es-rev.pdfJanuary 01, 2023 - ■ The change in racial and ethnic diversity has occurred largely in younger age groups. … The slowdown occurred after passage of several federal COVID-19-related bills, which included temporary … This was due, in part, to the emergence of more transmissible variants of the virus, which occurred … • Most COVID-19 deaths occurred among adults age 65 and over. … But large numbers of deaths also occurred among adults ages 50-64 and 18-49, especially during surges
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/024-ss-cusp-learning-from-defects.pptxApril 01, 2025 - What actions occurred? What were people thinking and feeling? … What else was happening at the time the defect occurred?
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/002-cusp-learning-defects.pptxOctober 01, 2024 - What actions occurred? What were people thinking and feeling? … What else was happening at the time the defect 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/vol4/Advances-Maddox_38.pdfMarch 26, 2008 - devices were used with critical care patient types, 52 percent of the highest risk-averted overdoses occurred … 11, 12, 13, 14 Leape, et al., showed that 38 percent of medication errors causing preventable ADEs occurred … Of the nonintercepted potential ADEs and preventable ADEs, 51 percent occurred during the administration … modules were used with critical care patient types, 52 percent of highest risk averted overdoses occurred … drug overdose, these overdoses would have been associated with 6-month costs of $1,968,000, had they occurred
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Learn-From-Defects-Facilitator-Guide (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.docxMay 01, 2017 - the event or issue by providing teams the tools and resources needed to make sense of a failure that occurred … happen—No-harm event Event did not reach the patient—Near-miss event We then ask why this consequence occurred … Try to view the world as they did when the event occurred. 2. Why did it happen? Step 1. -
Antibiotic-Patient-Safety-Facilitator-Guide (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/antibiotic-patient-safety-facilitator-guide.docxJune 01, 2021 - We’re only going to focus on those that occurred in the long-term care facility. … SAY: A second problem occurred when the daytime health care practitioner prescribed antibiotics. … Science of Safety SAY: Let’s apply the three basic principles of safe design to the problems that occurred
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