Email Updates
Go to Basic Search
Results
Total Results: 2,959 records
Showing results for "occurred".
-
www.ahrq.gov/research/shuttered/toolkitchecklist/surgetkit3.htmlJuly 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…
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module7/module7-resolution-facilitator.pptxAugust 24, 2015 - components: Taking responsibility—This is not admitting guilt, but rather admitting that an adverse event occurred
-
www.ahrq.gov/research/shuttered/toolkitchecklist/surgetkit1.htmlJuly 01, 2018 - change, the target facility may be sold, or regulatory changes or technological advancements may have occurred
-
www.ahrq.gov/antibiotic-use/long-term-care/four-moments/index.htmlAugust 01, 2021 - Four Moments of Antibiotic Decision Making The Four Moments of Antibiotic Decision Making are the critical time periods of antibiotic decision making. Frontline staff and prescribing clinicians are encouraged to use the Four Moments framework for all residents whenever the need for antibiotics is being c…
-
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.pdfApril 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 -
www.ahrq.gov/sites/default/files/2025-04/schiff-mcnutt-report.pdfJanuary 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
-
www.ahrq.gov/sites/default/files/2025-02/castle-report.pdfJanuary 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
-
Teamworknotes (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/implement/teamworknotes.docxJune 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 -
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-facilitator-guide.pdfMay 01, 2017 - In determining the defect that occurred, teams reconstruct the timeline of the event by placing themselves
-
www.ahrq.gov/patient-safety/resources/learning-lab/physiologic-monitoring-long-desc.htmlJanuary 01, 2025 - They also amplified actionable, critical alarms by directly calling the nurse when actionable alarms occurred
-
114-Mrsa-Prevention-Learning-From-Defects (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/114-mrsa-prevention-learning-from-defects.docxOctober 01, 2024 - Try to view the world as they did when the event occurred. -
www.ahrq.gov/news/newsletters/e-newsletter/952.htmlApril 01, 2025 - engagement—arrival, evaluation and treatment plan and disposition—they identified 237 barriers that occurred
-
www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-cognitive-load3.htmlMay 01, 2024 - Cognitive Load Theory and Its Impact on Diagnostic Accuracy Interplay Between Cognitive Load and Diagnostic Accuracy Previous Page Next Page Table of Contents Cognitive Load Theory and Its Impact on Diagnostic Accuracy Introduction to Diagnostic Errors Fundamental Concepts for Understanding Cogn…
-
www.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/chapter4.htmlAugust 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
-
www.ahrq.gov/sites/default/files/2024-12/danforth-report.pdfJanuary 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
-
www.ahrq.gov/sites/default/files/2024-01/gandhi-report.pdfJanuary 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
-
www.ahrq.gov/sites/default/files/2024-07/gallagher4-report.pdfJanuary 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
-
www.ahrq.gov/sites/default/files/2024-07/morrison-report.pdfJanuary 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
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/learn-from-defects-facguide.docxJanuary 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.
-
www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-slides.pptxJune 01, 2021 - Imagine the world as they did when the event occurred. 13 Changing the System 13 Why Did It Happen
SHARE:
Search the AHRQ Archive
Information and reports more than 5 years old may be found in the AHRQ Archive site.
Search Within A Specific AHRQ Site
You selected to view results for the following site:
