-
www.ahrq.gov/news/newsroom/press-releases/seniors-struggles-with-opioids.html
September 01, 2018 - In 2015, 124,300 hospitalizations and 36,200 ED visits occurred due to complications resulting from opioid
-
www.ahrq.gov/news/newsroom/press-releases/complications-hospital-births.html
September 01, 2018 - In 2015, for example, blood transfusions occurred with more than half of deliveries among mothers who
-
www.ahrq.gov/news/newsroom/case-studies/201718.html
April 01, 2018 - Responses to the CAHPS survey indicated that long wait times occurred frequently.
-
www.ahrq.gov/news/newsroom/case-studies/201707.html
May 01, 2017 - "The real achievement is the change of culture" that occurred as a result of the TeamSTEPPS training,
-
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
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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
-
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
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/prevehosp-reports-ig.pdf
November 30, 2013 - 8-30 days
31-90 days
If no ED visits occurred in the past 90 days, the field is blank. … This section displays
the number of hospitalizations that occurred in the following
timeframes: … 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.
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cauti-learning-from-defects.docx
April 01, 2022 - (Communication Plan) Now that you have more information about how and why this CAUTI occurred, how will
-
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
-
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
-
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
-
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
-
www.ahrq.gov/news/newsroom/case-studies/201809.html
January 01, 2019 - use of an indwelling catheter is considered appropriate and consider whether an infection may have occurred
-
www.ahrq.gov/patient-safety/resources/simulation-issue-brief3.html
July 01, 2024 - Simulation That Revealed an Equipment Malfunction A patient safety event occurred when an infusion delivered
-
www.ahrq.gov/health-literacy/professional-training/lepguide/app-b.html
September 01, 2020 - This case highlights a situation that could have occurred in any hospital around the country. … The next level of missed opportunity occurred at the level of the triage nurse.
-
www.ahrq.gov/sites/default/files/2024-07/mazor-report.pdf
January 01, 2024 - healthcare systems to respond to a specific adverse
event or error and to determine how the event occurred … This growing emphasis on adverse event reporting has occurred alongside an understanding that patients … Hospital-level adaptation of the WWTK-Core program occurred as the program was disseminated and adopted … Of the 94 reports of breakdowns, 90 (95.7%)
indicated that harm had occurred. … Of the 23 reports, 22 (95.7%)
indicated that harm had occurred.
-
www.ahrq.gov/patient-safety/resources/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
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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
-
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