Results

Total Results: 4,281 records

Showing results for "occurred".

281. The New York Model: Root Cause Analysis Driving Patient Safety Initiative to Ensure Correct Surgical and Invasive Procedures (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Faltz_56.pdf
     March 27, 2008 - These errors occurred in a wide variety of locations (Table 3). Table 3. … Of the latter, two of the four cases occurred when the vendor representative handed the wrong component … Presentations included a detailed description of a recent wrong-sided surgical sentinel event that occurred … Of these, two-thirds occurred in settings other than the operating room.

282. Final Progress Report: A Novel Debriefing Strategy for Interprofessional Simulation-Based Team Training (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/27493-VanSchaik-report.pdf
     December 31, 2022 - On the rare occasions that interprofessional co-facilitation occurred prior to implementation of the … When this occurred, the discussion was brief and limited to generic statements about the importance … Discussions about medical management were less physician focused and more frequently occurred in the … Perspective taking was uncommon, and mostly occurred in the context of physician participants explaining … If so, why do you think they occurred?

283. Making Healthcare Safer for Older, Vulnerable Patients | Agency for Healthcare Research and Quality
     www.ahrq.gov/funding/grantee-profiles/grtprofile-gurwitz.html
     September 01, 2019 - observational study, published in JAMA Internal Medicine in July 2019, found that adverse events occurred

284. Leading Teams (Instructor Guide) (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module4/ts2-0ltc_module4_ig_lead.pdf
     May 10, 2017 - When emergencies have occurred at these events in the past, many people come running and there is … include: • Accurate recounting and documentation of key events; • Analysis of why the event occurred … • Recap the situation, background, and key events that occurred. … • Accurate recounting and documentation of key events; • Analysis of why the event occurred, what worked

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

286. 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.

287. Transforming Primary Care Practice in North Carolina | Agency for Healthcare Research and Quality
     www.ahrq.gov/ncepcr/funding/grants/transform/profiles/donahue.html
     July 01, 2022 - When this occurred, the work of the practice coaches, use of registries, and data collection were generally

288. 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

289. Federal Interagency Workgroup on Improving Diagnostic Safety--March Meeting Summary (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/topics/DxSafety-March2019-MeetingNotes.pdf
     March 08, 2019 - Workgroup Summary: The workgroup meeting occurred on March 8, 2019, and was attended by representatives

290. 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

291. 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

292. 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

293. Identify Defects Through Sensemaking, Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/modules/identify/notes.html
     December 01, 2012 - 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.

294. Medical and Dental Groups Use AHRQ Research to Revise Recommendations for Routine Antibiotic Use | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/coe0806.html
     October 01, 2014 - This usually occurred at routine dental office visits.

295. Technology Based on AHRQ-Funded Research Used to Track Tuberculosis in Homeless | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/cp31308.html
     May 01, 2013 - central registry improved communication among service providers and reduced duplicate testing that occurred

296. 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

297. 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

298. 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

299. 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

300. Data Measures Guide (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/vae/datameasures-guide.pdf
     January 01, 2017 - Mobility Intubated: Adverse Event Incidence Rate Numerator Total number of adverse events which occurred … Example In a given time period, say a unit enters the following data: • Adverse events (4) and (7) occurred … of Adverse Events Numerator Total number of adverse events in each of the 25 categories which occurred … NOT Intubated: Adverse Event Incidence Rate Numerator Total number of adverse events which occurred … Total number of patient days with Intub/Trach & Mech Vent marked “N” on which any adverse event(s) occurred