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Showing results for "occurred".
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Gallagher2.pdfJanuary 01, 2016 - The area-level definition adds cases where a patient’s risk of the complication occurred in a separate … Selected Infections Due to Medical Care hospital-level PSI was developed to capture adverse events that occurred … approach Calculation of counts and rates The rate of Selected Infections Due to Medical Care that occurred … intravenous line and catheter-related infections, as measured by a secondary diagnosis of septicemia, occurred
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www.ahrq.gov/patient-safety/settings/hospital/match/appendix/app-5.htmlJuly 01, 2022 - Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation Appendix, Develop a Flowchart of Your Current Medication Reconciliation Process Previous Page Next Page Table of Contents Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Rec…
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www.ahrq.gov/es/patient-safety/settings/hospital/match/appendix/app-5.htmlJuly 01, 2022 - Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation Appendix, Develop a Flowchart of Your Current Medication Reconciliation Process Previous Page Next Page Table of Contents Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Rec…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/patfamilyengagement/CUSP_Patient_Family_Engagement_Facilitator_Notes.docxJune 02, 2025 - 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 if patient harm occurred
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-pda.pdfJune 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…
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Four Moments Poster (pdf file)
www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/four-moments/poster-one-option.pdfNovember 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… -
www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/understand-sci-fac-guide.htmlJuly 01, 2023 - In determining the defect that occurred, teams reconstruct the timeline of the event by placing themselves
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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.docxMay 01, 2017 - In determining the defect that occurred, teams reconstruct the timeline of the event by placing themselves -
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/learn-from-defects-slides.pptxJanuary 01, 2017 - What actions occurred? What were care team members thinking and feeling?
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-catheter-maintenance-notes.docxApril 01, 2022 - It is not uncommon to find that these breaks occurred and were not evaluated at that time.
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes7.htmlAugust 01, 2022 - : Taking responsibility—This is not admitting guilt, but rather admitting that an adverse event occurred
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/four-moments-explained.pdfJune 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…
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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.docxApril 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. -
www.ahrq.gov/patient-safety/settings/hospital/candor/impguide.htmlAugust 01, 2022 - Investigation and Analysis has been completed, which will take place within 30-45 days after the event occurred
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4.htmlAugust 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
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www.ahrq.gov/patient-safety/reports/liability/neumiller.htmlAugust 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
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www.ahrq.gov/research/findings/final-reports/stpra/stpra4.htmlApril 01, 2018 - care workers learn these strategies on the job, in the setting where a serious or sentinel event has occurred
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www.ahrq.gov/sites/default/files/2024-01/cohen-report.pdfJanuary 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%
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Davis_60.pdfApril 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
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www.ahrq.gov/hai/tools/surgery/modules/sustainability/learn-from-defects-slides.htmlDecember 01, 2017 - What actions occurred? What were care team members thinking and feeling?
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