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Total Results: 2,959 records

Showing results for "occurred".

281. The Contribution of Diagnostic Error to Maternal Mortality and Severe Maternal Morbidity | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/maternal-mortality-2.html
     September 01, 2021 - Estimated blood loss at this point was >2,000 mL. c Delays in blood transfusion occurred due to the

282. AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/prev-handouts.html
     December 01, 2017 - readmission _X_ With a change in condition _X_ With each MDS assessment ___ When weight loss has occurred … develop nutritional interventions for residents with weight loss, but that's after the weight loss has occurred … happening at this nursing home, but their focus seems to be on reacting to adverse events that have already occurred … readmission ___ With a change in condition _X_ With each MDS assessment ___ When weight loss has occurred … to analyze the circumstances leading up to the event with the goal to identify how and why the event occurred

283. Mixed Methods Analysis of Medical Error Event Reports: A Report from the ASIPS Collaborative (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Harris.pdf
     June 30, 2004 - This finding suggested that we focus our qualitative analysis on determining where and how the error occurred … issues influenced diagnostic testing errors, at what point in the procedure event chain the error occurred … , how and why it occurred, and why harm did or did not occur. … Contributing and mitigating factors are necessary for the event to have occurred the way it did, whereas … The ability to draw on real examples of errors that occurred in the practices participating in ASIPS

284. On-Time Preventable Hospital and Emergency Department Visits (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/2-preventablehospitalandedvisits-samplerpts_3.pdf
     November 30, 2013 - This section displays the number of ED visits that occurred in the following timeframes: • 0-7 days … This section displays the number of hospitalizations that occurred in the following timeframes: • … multiple data sources within the facility’s electronic medical record and represent changes that occurred … potential root causes (e.g., treatment unavailable at facility, treatments prior to transfer) that occurred … the visits were for potentially preventable conditions, the time of day/day of week the transfers occurred

285. Surveillance of Surgery-related Adverse Events in Missouri Using ICD-9-CM Codes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Tuinen.pdf
     March 01, 2004 - Some attrition occurred during data collection due to factors such as unavailable charts, inadequate … Only 10 percent on average failed because the codes in the class were judged to refer to events that occurred … were an accurate representation of the charts and whether they could identify patients with AEs that occurred … These classes did have a few codes specific to surgical complications, but the codes occurred very infrequently … Several of the ICD codes occurred with low frequency in our sample but are fairly frequent in the discharge

286. References (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/subglottic-litreview.docx
     January 01, 2017 - Dysfunction of the suction lumen occurred in 19 of 40 patients, 17 of which were attributable to blockage … During ventilation, microbilogically confirmed VAP occurred in 15 patients (8.8%) of group 1 and 32 patients … Microbiologically confirmed VAP occurred in 67 patients, 25 of 169 (14.8%) in the SSD group and 42 of … Dysfunction of the suction lumen occurred in 19 of the 40 patients (48%). … Episodes of VAP occurred statistically later among patients receiving continuous suctioning ([mean ±

287. EXCEL WORKSHEETS FOR CHARTS ON DATA, TRENDS, AND RATES TO POPULATE THE POWERPOINT PRESENTATION (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/b3a_pdi_chartinstructions.pdf
     June 02, 2025 - The observed rate is the actual rate at which events measured by the indicator occurred in your hospital

288. EXCEL WORKSHEETS FOR CHARTS ON DATA, TRENDS, AND RATES TO POPULATE THE POWERPOINT PRESENTATION (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/b3a_combo_chartinstructions.pdf
     June 02, 2025 - The observed rate is the actual rate at which events measured by the indicator occurred in your hospital

289. Sickle Cell Disease Measure 16: Appropriate Emergency Department Pain Assessment for Children With Sickle Cell Disease (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-0217-scd-pain-specifications.pdf
     June 02, 2025 - Acute pain episode: Considered to have occurred if there is any documentation of a Numeric Pain Intensity

290. AHRQ Views: Feeling Energized After Another Successful AcademyHealth Annual Research Meeting | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsletters/e-newsletter/921.html
     July 01, 2024 - Medical Visits in 2021 Conducted Using Telehealth Nearly 10 percent of all U.S. medical visits in 2021 occurred

291. Chesapeake Regional Healthcare’s Success in Preventing Falls in Hospitals | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/about/chesapeake-regional-healthcare.html
     February 01, 2024 - by Risk Management, the Nursing Quality Specialist, and the Nurse Manager of the unit where the fall occurred

292. Chapter 3. Description of Methods | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/chapter3.html
     August 01, 2022 - About 88 percent of the patient safety events occurred in a hospital setting. … One quarter of patient safety events occurred in an ambulatory setting and 10 percent in a long-term … patients, family members, and others to be able to report a patient safety event from the time the event occurred … Among the participants, about 91 percent reported that the event occurred in a hospital setting, 21 percent … recommendations did not guarantee a response from the health care setting where the patient safety event occurred

293. Transforming Primary Care Practice in North Carolina (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/tpc/tpc-profile-donahue.pdf
     April 01, 2015 - When this occurred, the work of the practice coaches, use of registries, and data collection were generally

294. Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors, Volume 2: Eliciting Patient Narratives (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-patient-experience-vol2.pdf
     July 01, 2023 - persist for many years, elicitation techniques must inquire about the impact of adverse events that occurred … term aftermath of perceived diagnostic mishaps, one must elicit patient experiences about events that occurred … past 5 years.16 Stratifying elicited experiences based on how many years earlier the adverse event occurred … sequenced to help patients reflect on their experiences, recount events in the order in which they occurred … situations that pose the greatest challenges for patients and families to reliably assess what has occurred

295. Patient Safety Learning Pilot: Narratives from the Frontlines (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Kellie_30.pdf
     April 21, 2008 - the antecedent activities and decisions provide significant information as to how the recovery occurred … frequent than actual events, but they rarely reported them because they felt that the recoveries that occurred … which is completed by the involved staff members at the time that the event is recognized to have occurred … Rather, they moved to understand the causes of the process failures that had occurred and made the recovery … The failure to transcribe the order occurred at the pharmacy, largely due to lack of pharmacy understanding

296. Early-Mobility-Tool (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/early-mobility-tool.docx
     January 01, 2017 - Unknown: it is unknown regarding what activity, if any, occurred 0. … Unknown: it is unknown regarding what activity, if any, occurred Perceived barrier to achieving a higher … If multiple events occurred, you can enter up to two more events.

297. Daily Early Mobility Data Collection Tool | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/modules/technical/early-mobility-tool.html
     January 01, 2017 - Unknown : it is unknown regarding what activity, if any, occurred. … Unknown : it is unknown regarding what activity, if any, occurred. … If multiple events occurred, you can enter up to two more events.

298. Measure Dx: A Resource To Identify, Analyze, and Learn From Diagnostic Safety Events (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/MeasureDx-guide.pdf
     July 01, 2022 - Queries cannot confirm that a missed opportunity occurred, why it occurred, or whether it was preventable … Cases were reviewed by a multidisciplinary QI team to determine if a diagnostic error occurred. … that reached the patient but did not cause patient harm � Category D- An error occurred that reached … that may have contributed to or resulted in permanent patient harm � Category H- An error occurred … that required intervention necessary to sustain life Error, Death � Category I- An error occurred that

299. Measure Dx: A Resource To Identify, Analyze, and Learn From Diagnostic Safety Events (pdf file)
     www.ahrq.gov/sites/default/files/publications2/files/MeasureDx-guide.pdf
     July 01, 2022 - Queries cannot confirm that a missed opportunity occurred, why it occurred, or whether it was preventable … Cases were reviewed by a multidisciplinary QI team to determine if a diagnostic error occurred. … that reached the patient but did not cause patient harm � Category D- An error occurred that reached … that may have contributed to or resulted in permanent patient harm � Category H- An error occurred … that required intervention necessary to sustain life Error, Death � Category I- An error occurred that

300. Improvement Data | Agency for Healthcare Research and Quality
     www.ahrq.gov/pqmp/implementation-qi/toolkit/tcd/improvement-data.html
     July 01, 2021 - The first QMETRIC SCD Expert Design (also referred to as the SCD Trailblazer) meeting occurred in December