Results

Total Results: 2,792 records

Showing results for "occurred".

201. Final Progress Report: Improving Safety of Transitions to Skilled Nursing Care Using Video Conferencing (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/lipsitz-report.pdf
     January 01, 2024 - Two physicians independently reviewed each TCE to determine if a medical error had occurred. … A total of 1432 discussions occurred for 1326 patients.

202. Sensemaking and Learn from Defects for Perinatal Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.pdf
     May 01, 2017 - event or issue by providing teams the tools and resources needed to make sense of a failure that occurred … Perinatal Care Sensemaking & Learn From Defects 10 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.

203. AHRQ_Brand_NameOnly (xls file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/sustainability/sustainability-assesment-tool.xlsx
     March 01, 2017 - My team has a good process in place to monitor and track infections, and examine why they occurred if … able to answer The team has a process in place to monitor and track infections, and examine why they occurred … The team has a process in place to monitor and track infections, and examine why they occurred.4 The

204. Penicillin Allergy (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/penicillin-allergy-one-pager.pdf
     September 01, 2022 - 4 • If the reaction occurred more than 10 years ago, the patient may no longer have an allergy because

205. Appendix, MATCH Resources for Patients | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/match/appendix/app-12.html
     July 01, 2022 - including tips for using medications wisely and suggestions on what to do if you think an error has occurred

206. Appendix, MATCH Resources for Patients | Agency for Healthcare Research and Quality
     www.ahrq.gov/es/patient-safety/settings/hospital/match/appendix/app-12.html
     July 01, 2022 - including tips for using medications wisely and suggestions on what to do if you think an error has occurred

207. Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Healthcare (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/topics/public-notes-meeting-summary-072221.pdf
     November 19, 2021 - Workgroup Summary: The latest Workgroup meeting occurred virtually on July 22, 2021, from 10 a.m. to

208. Problem Solving and Escalation – Standards Component Kit | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/management/problem-solving-comp-kit.html
     June 01, 2017 - CUS contact person determines what communication has occurred with the patient/family regarding the event … If communication has not yet occurred and is required, CUS contact person will speak with the patient

209. Implement Teamwork and Communication | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/modules/implement/teamwork.html
     December 01, 2012 - Exercise Think of a defect that has occurred in your unit due to a communication breakdown. … Feedback 1 Timely—given soon after the target behavior has occurred.

210. A Conceptual Framework for Studying the Safety of Transitions in Emergency Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Behara.pdf
     January 01, 2004 - other differences in work patterns among the various hospitals, very different sorts of handovers occurred … Some occurred in the workplace, while other handovers took place what might be referred to as a “backstage … In our observations, however, only three of the eight potential combinations occurred with any frequency … nature pertained to joint handovers (i.e., involving both physicians and nurses), which almost never occurred … In the two settings that did use nurse-physician teams, however, handovers still occurred separately

211. Medication Management Transactions and Errors in Family Medicine Offices: A Pilot Study (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Lynch_37.pdf
     March 21, 2008 - cases, it was the phone or fax that was responsible for mitigating the error but not how the error occurred … For new chronic medications, errors occurred in 74.2 percent of encounters; for renewal of existing … processes occurring when the error was discovered rather than the circumstances at the time that the error occurred … mitigation event is identified, a retrospective review should track back to the encounter where the error occurred … Many of these errors might not have occurred with electronic prescribing embedded in an electronic medical

212. Pf-Engagement-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/pf-engagement-facilitator-guide.docx
     May 01, 2017 - Generally, only findings that are reasonably certain to have occurred and unlikely to change should be … investigate and analyze it (e.g., a root cause analysis may be conducted) to determine whether patient harm occurred

213. Tool 2: Readmission Review Tool (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/mcaidread_tool2_readm_review.docx
     June 02, 2025 - The purpose of these interviews is to elicit the “story behind the chief complaint”—the events that occurred

214. Ambulatory Pediatric Patient Safety Learning Lab: Pursuing Safe Healthcare at Home | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/learning-lab/ambulatory-pediatric-long-desc.html
     January 01, 2025 - If communication delays occurred, the electronic health record (EHR) triggered a message to nurses to

215. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/intro.html
     June 01, 2017 - residents who have had a recent preventable hospital visit to help staff evaluate why these transfers occurred

216. Appendix K. Quality Improvement Study Framework - Implementation Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/implementation-guide/study.html
     May 01, 2017 - Include— Frequency: How often the issue occurred in your study period Sources: Potential reasons

217. Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module4/guide.docx
     March 01, 2017 - facility leaders and administrators to share information with residents/families when an event has occurred

218. BLADDER SCAN – POLICY #2202 12/11/06 (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/resources/tools/implement/facility-action-plan.docx
     January 01, 2018 - has done to communicate and share survey results with staff, and an understanding of what benefits occurred

219. Development and Validation of the Medication Administration Error Reporting Survey (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Wakefield2.pdf
     January 01, 2003 - First, by definition, recognition that an error has occurred means that the error happened some time … Because of this, recognition that an error has occurred is very difficult.20 Second, even if an error … activities leading to patients receiving medication, they are often “blamed” for errors that may have occurred … When errors occur, they are likely to be viewed as failures of character (i.e., the error occurred … • Nurses do not recognize an error occurred. • Medication error is not clearly defined.

220. AHRQ WebM&M—Online Medical Error Reporting and Analysis (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Wachter.pdf
     March 11, 2005 - Thirty-seven errors (67 percent) occurred in hospital, while 8 errors (14.5 percent) occurred in emergency … departments (without subsequent admission); 8 errors (14.5 percent) occurred in ambulatory practices … points” for providers and quality leaders alike, while honestly identifying individual error where it occurred