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Total Results: 2,792 records

Showing results for "occurred".

301. NICU Family Information Packet, Appendix B, Patent Ductus Arteriosus (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-pda.pdf
     June 02, 2025 - NICU Family Information Packet, Appendix B, Patent Ductus Arteriosus Patent Ductus Arteriosus Characteristics ■ A persistent open connection beyond 3 months of age between the pulmonary artery and the aorta with blood flow from the aorta to the pulmonary artery. ■ An open ductus may lead to: – Congestive heart…

302. Four Moments Poster (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/four-moments/poster-one-option.pdf
     November 01, 2019 - Four Moments Poster AHRQ Pub. No. 17(20)-0028-EF November 2019 Moment 1 occurs at the time initiation of antibiotic therapy is considered: Ask, “Does my patient have an infection that requires antibiotics?” occurs when the dec…

303. Understand-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-facilitator-guide.docx
     May 01, 2017 - In determining the defect that occurred, teams reconstruct the timeline of the event by placing themselves

304. Presentation: Program Overview
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/learn-from-defects-slides.pptx
     January 01, 2017 - What actions occurred? What were care team members thinking and feeling?

305. Indwelling Urinary Catheter Maintenance Facilitator Notes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-catheter-maintenance-notes.docx
     April 01, 2022 - It is not uncommon to find that these breaks occurred and were not evaluated at that time.

306. Final Progress Report: Cook County & Rush Developmental Center for Research in Patient Safety: Diagnosis Error Evaluation and Research (DEER) Project (pdf file)
     www.ahrq.gov/sites/default/files/2025-04/schiff-mcnutt-report.pdf
     January 01, 2025 - Even to agree whether or not an error has occurred is difficult. … It identifies what went wrong, situating where in the diagnostic process the failure occurred. … We strove to examine a) whether error had occurred, b) how it had occurred, and c) ways it might have … answer 7 and needed to reach conclusions about in order to determine whether and how errors had occurred … but things might have been done differently/better, to more egregious errors that should never have occurred

307. Final Progress Report: Incident Reporting Practices in Nursing Homes (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/castle-report.pdf
     January 01, 2025 - used to track, monitor, or maintain data, with 33% of NHs reporting that quality improvement analyses occurred … These were (1) “lack of recognition that an adverse event has occurred”; (2) “fear of liability, lawsuits … collection format and analysis of data and most incident reporting systems describe only that an incident occurred … Likelihood (SEM †) Barrier Classification Rank ‡ Lack of recognition that an adverse event has occurred … documenting an adverse event 2.19 (0.06) Individual 5 Difficulty in proving that an adverse event actually occurred

308. 003-Ss-Antimicrobial-Prophylaxis-Part-2-Fg (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/003-ss-antimicrobial-prophylaxis-part-2-fg.docx
     April 01, 2025 - The authors found that acute kidney injury (AKI) occurred in 8.8 percent of patients, similar to what … When assessing timing, also ask how many years ago this reaction occurred. … When taking an allergy history, staff should ask the patient what type of reaction occurred, such as … Have the patient describe the rash and when it occurred after taking penicillin.

309. Teamworknotes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/implement/teamworknotes.docx
     June 02, 2025 - Slide 7 DO: Think of a defect that occurred on your unit because of a communication breakdown. … debriefings include: · An accurate recounting and documenting of key events, · An analysis of why an event occurred … This tool provides physicians and nurses a structured approach to review problems that may have occurred

310. System-Focused Event Investigation and Analysis Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4.html
     August 01, 2022 - If a normal error has occurred, the provider undoubtedly feels bad and should be supported. … technology, the information, and the processes are all critical clues to the context in which the event occurred … the context is best done through observations of normal work flow in the environment where the event occurred … It is an opportunity for everyone to understand the event, why it occurred, and confirm contributing

311. Implementation Guide for the CANDOR Process | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/impguide.html
     August 01, 2022 - Investigation and Analysis has been completed, which will take place within 30-45 days after the event occurred

312. Pediatric Patient Safety Learning Laboratory to Reengineer Continuous Physiologic Monitoring Systems | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/learning-lab/physiologic-monitoring-long-desc.html
     January 01, 2025 - They also amplified actionable, critical alarms by directly calling the nurse when actionable alarms occurred

313. 114-Mrsa-Prevention-Learning-From-Defects (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/114-mrsa-prevention-learning-from-defects.docx
     October 01, 2024 - Try to view the world as they did when the event occurred.

314. AHRQ Celebrates National Public Health Week | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsletters/e-newsletter/952.html
     April 01, 2025 - engagement—arrival, evaluation and treatment plan and disposition—they identified 237 barriers that occurred

315. Medication Discrepancies and Potential Adverse Drug Events During Transfer of Care from Hospital to Home | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/liability/neumiller.html
     August 01, 2017 - The 6 discrepancies determined to potentially result in a severe ADE occurred in 6 individuals, while … 386 ADEs were rated as significant and 174 rated as minor occurred in 152 and 174 individual patients … Gandhi and colleagues estimated that ADEs occurred at a rate of 27.4 per 100 ambulatory patients, with

316. Four Moments of Antibiotic Decision Making Explained (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/four-moments-explained.pdf
     June 01, 2021 - Four Moments of Antibiotic Decision Making Explained Moment 1 occurs when a resident is assessed for a change in status and there is a concern for infection. Sometimes long-term care staff recognize that something is not quite right with the resident but aren’t clear on what is wrong. The person doing the assessmen…

317. Final Progress Report: Using Barcode Technology to Improve Medication Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/gandhi-report.pdf
     January 01, 2024 - beginning with planning, through development and implementation, to steady-state operations (which occurred … The break-even point for the hospital’s investment occurred in the first quarter of the fourth year, … $2.99 million (90% CI, $763,000 to $5.83 million), and the break-even point for return on investment occurred

318. Final Progress Report: Enhancing the Disclosure Of Medical Errors to Patients (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/gallagher4-report.pdf
     January 01, 2024 - mentioned the adverse event but not the error, but 42 percent would explicitly state that an error occurred … When errors occurred, nurses felt they should be disclosed but questioned this generality for anxious … After errors occurred, nurses reported poor communication among the team about what patients had or

319. Final Progress Report: Electronic Communications Across Provider Settings (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/morrison-report.pdf
     January 01, 2024 - Scope The planning for ECAPS occurred in two rural settings. … architecture that is open and automates the process of alerting other providers to changes that have occurred

320. Failure Modes and Effects Analysis Based on In Situ Simulations: A Methodology to Improve Understanding of Risks and Failures (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Davis_60.pdf
     April 07, 2008 - failure mode based on three factors: (1) its likelihood of occurrence (L), (2) its severity if it occurred … This failure mode occurred in every simulation trial, and in situ participants repeatedly identified … Again, this failure mode occurred in every simulation and resulted in delays in receiving blood and/ … team in the operating room assumed that the blood bank would be sending the blood, neither of which occurred