Results

Total Results: 2,792 records

Showing results for "occurred".

321. Final Report: Using Risk Models To Improve Safety With Dispensing High-Alert Medications in Community Pharmacies (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/cohen-report.pdf
     January 01, 2024 - No changes to the fault trees occurred as a result of comparison to published studies about medication … When counseling occurred, the focus on how to use the patch correctly, rather than assuring the appropriateness … The effect of this change occurred primarily in the order entry process section of the fault tree, when … The team estimated that 90% of the errors would be captured if an independent verification process occurred … Counseling the patient had limited value, because it occurred infrequently (30%) and carried an 80%

322. Chapter 4. Results and Key Findings | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/chapter4.html
     August 01, 2022 - The systems should capture both objective information about what occurred and more subjective information … Information collected from consumers should include where a patient safety event occurred; what contributed … submitted to relevant health care facilities (presumably facilities where events of the specified type occurred

323. Executive Summary | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/summary.html
     August 01, 2022 - The systems should capture both objective information about what occurred and more subjective information … Information collected from consumers should include where a patient safety event occurred; what contributed … submitted to relevant health care facilities (presumably facilities where events of the specified type occurred

324. Mod4-System-Focused-Event-Guide (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4/mod4-system-focused-event-guide.pdf
     April 01, 2016 - If a normal error has occurred, the provider undoubtedly feels bad and should be supported. … 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 … This format helps to utilize the information found in the investigation to understand why the event occurred … Confirmation and Consensus Meeting Announcement Template As you may know, a patient care incident occurred

325. Chapter 4. Conclusions and Next Steps | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/stpra/stpra4.html
     April 01, 2018 - care workers learn these strategies on the job, in the setting where a serious or sentinel event has occurred

326. Sustainability: Learning From Defects: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/surgery/modules/sustainability/learn-from-defects-slides.html
     December 01, 2017 - What actions occurred? What were care team members thinking and feeling?

327. How to Use This Toolkit | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/shuttered/toolkitchecklist/surgetkit1.html
     July 01, 2018 - change, the target facility may be sold, or regulatory changes or technological advancements may have occurred

328. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module7/module7-resolution-facilitator.pptx
     August 24, 2015 - components: Taking responsibility—This is not admitting guilt, but rather admitting that an adverse event occurred

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

330. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/learn-from-defects-facguide.docx
     January 01, 2017 - What actions occurred? What were the team members thinking and feeling? … SAY: Asking these questions, and others, can help you understand how a defect occurred. … SAY: Try to find out what occurred in real time.

331. AHRQ's Safety Program for Nursing Homes: On-Time Falls Prevention Training (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/fallspximpl-handouts.pdf
     June 02, 2025 - All department heads attend and we do talk about falls that occurred. Dr. … We have a falls meeting, but we don’t talk about falls risk; we talk about falls that have occurred … Report, the team will be able to identify patterns regarding falls such as what time of day they occurred … These are falls that occurred during the quarter. … The Falls Risk Report provides a count of all risk factors associated with the falls that have occurred

332. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/vae/monitoring-vae-facguide.docx
     January 01, 2017 - and objective outcome measures, and correctly apply VAE diagnostic criteria to determine if a VAE has occurred … POTENTIAL VAC SAY: We will now use the VAC criteria reviewed earlier to determine whether a VAC has occurred

333. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-slides.pptx
     June 01, 2021 - Imagine the world as they did when the event occurred. 13 Changing the System 13 Why Did It Happen

334. Tool: Formative Feedback | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps-program/curriculum/mutual/tools/feedback.html
     June 01, 2023 - Feedback delivered several weeks after poor or excellent behaviors have occurred is too late for maximum

335. Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Healthcare July 2020 Meeting Summary (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/topics/public-notes-meeting-summary-072320.pdf
     November 06, 2020 - Workgroup Summary: The latest Workgroup meeting occurred virtually on July 23, 2020, and was attended

336. Equipment and Supplies | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/shuttered/toolkitchecklist/surgetkit3.html
     July 01, 2018 - Equipment and Supplies Public Health Emergency Preparedness 1. Preplanning Description: The equipment and supplies team must lay the groundwork for procurement prior to a surge event. Key decisions include: determining whether to outsource staffing and procurement of the equipment and supplies, deciding wh…

337. Final Progress Report: Electronic Clinical Surveillance To Measure and Improve Safety in Ambulatory Care (pdf file)
     www.ahrq.gov/sites/default/files/2024-12/danforth-report.pdf
     January 01, 2024 - initially abnormal estimated glomerular filtration (eGFR) rate for diagnosis of chronic kidney disease occurred … In brief, we found that medication dispenses after a fall occurred among 35% of the study population

338. Measurement | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/guides/implguide-pt4.html
     October 01, 2015 - who cared for the patient just before their symptoms began improves understanding of any risks that occurred

339. Key Driver 2: Implement a Data-driven Quality Improvement Process to Integrate Evidence into Practice Procedures | Agency for Healthcare Research and Quality
     www.ahrq.gov/evidencenow/tools/keydrivers/implement-qi.html
     November 01, 2018 - results – including team-specific results – with practice goals will confirm if planned changes have occurred

340. Slide 1 (ppt file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/contentcalls/clabsi_invest-slides/CLABSI-Investigation-Walk-the-Process-Sept-14-2010-508.ppt
     January 01, 2010 - These have occurred in one ICU or another across many of the ICUs in our hospital and in hospitals we