Results

Total Results: 4,281 records

Showing results for "occurred".

221. Silence A Commentary | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/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

222. UChicago Medicine Reduces Perioperative Venous Thromboembolism with AHRQ's Toolkit | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/about/uni-chicago-medicine.html
     February 01, 2024 - institution when comparing calendar year January–July 2022 to January–July 2023, the most visible advances occurred

223. CANDOR Helped Significantly Reduce Patient Safety Events, Malpractice Claims at MedStar Health | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/201712.html
     September 01, 2017 - gathering information to be able to answer all of their questions about the possible preventable harm that occurred

224. Summary (Instructor Guide) (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module7/ts2-0ltc_module7_ig_summary.pdf
     May 10, 2017 - • Identify the instances where a breakdown in teamwork has occurred as it relates to the specific … Scenario A gastrointestinal outbreak has occurred within the nursing home and has affected the entire … – A better handoff would have occurred.

225. Chapter 3. Development of the Data Infrastructure | Agency for Healthcare Research and Quality
     www.ahrq.gov/practiceimprovement/delivery-initiative/ihs/chapter3.html
     December 01, 2017 - The identified differences were minimal and were primarily due to registration updates that occurred … Admissions that occurred within 30 days of a previous inpatient discharge were identified as readmissions … Diabetes education visits are visits that occurred in diabetes education clinics and are not counted

226. Patient and Family Engagement for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/pf-engagement-fac-guide.html
     July 01, 2023 - 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

227. Using Six Sigma® Methodology to Improve Handoff Communication in High-Risk Patients (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Mistry_114.pdf
     May 05, 2008 - Define,” “Measure,” and “Analyze” steps of the Six Sigma framework—communication errors frequently occurred … centered on establishing a team handoff model and modifying the environment in which the handoffs occurred … Specifically, only patient-specific conversation or urgent clinical interruptions occurred during the … overcome a time-consuming procedure.27 Furthermore, errors in the use of aviation checklists most often occurred … Conclusion We found that communication delays commonly occurred during the handoff process of patients

228. Creating Standards for Communication and Resolution When Things Go Wrong | Agency for Healthcare Research and Quality
     www.ahrq.gov/funding/grantee-profiles/grtprofile-gallagher.html
     May 01, 2020 - when he couldn’t find guidelines for physicians on how to talk with patients when an error or problem occurred

229. Sensemaking and Learn From Defects for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/perinatal-care/modules/teamwork/learn-from-defects-fac-guide.html
     May 01, 2017 - 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.

230. 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.docx
     May 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.

231. Learning From Defects
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/024-ss-cusp-learning-from-defects.pptx
     April 01, 2025 - What actions occurred? What were people thinking and feeling? … What else was happening at the time the defect occurred?

232. SSM Health Care | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/cquips0803.html
     October 01, 2014 - The use of case histories from the units where clear team failures have occurred helps to reinforce the

233. Tennessee Medical Center Uses AHRQ Tools to Reduce Infections, Medical Errors | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/201710.html
     June 01, 2017 - Thanks to CUSP, only 45 such errors occurred in 2015.

234. Albuquerque Police Department Uses AHRQ Resources for Crisis Intervention Team Training | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/201708.html
     May 01, 2017 - Of 2,064 crisis intervention-related incidents that occurred from January through November 2016 in the

235. Five Nebraska Hospitals Use AHRQ Toolkit to Improve Medication Reconciliation Across Care Settings | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/ktcquips82.html
     October 01, 2014 - By creating a flowchart of the medication reconciliation process that occurred from hospital discharge

236. AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/intro.html
     November 01, 2017 - the facility team with information to assist them in analyzing resident fall risks, falls that have occurred

237. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-2.html
     June 01, 2023 - about medical mishaps, inducing disparities in error reporting. 10 Might erroneously presume errors occurred

238. Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Health Care November Meeting Summary (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/topics/fed-IWG-dxsafety-Nov19mtg.pdf
     November 15, 2019 - Workgroup Summary: The latest workgroup meeting occurred virtually on November 15, 2019, from 10 a.m

239. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-2.html
     June 01, 2023 - about medical mishaps, inducing disparities in error reporting. 10 Might erroneously presume errors occurred

240. 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.