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Total Results: 2,792 records

Showing results for "occurred".

341. Diagnostic Safety Centers of Excellence Grants Awarded in FY 2022 | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/research/grants-2022.html
     August 01, 2025 - what went wrong, how delays could be avoided, and what strategies could mitigate any harm that has occurred … electronically identify patients who may have experienced errors and delays in diagnosis and understand why they occurred

342. Facilitator-Notes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module4/facilitator-notes.docx
     March 01, 2017 - investigate and analyze it (for example, conduct a root cause analysis) to determine if resident harm occurred

343. Interplay Between Cognitive Load and Diagnostic Accuracy | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-cognitive-load3.html
     May 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…

344. Appendix A. SIDM Competencies To Improve Diagnosis and Suggested Questions for Debriefing Case Studies | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/nurse-role-dxsafety-apa.html
     September 01, 2022 - What systems are in place here to ensure that appropriate followup has occurred?

345. Understand the Science of Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/modules/understand/science-safety-notes.html
     July 01, 2018 - In determining the defect that occurred, teams reconstruct the timeline of the event by placing themselves … This tool provides physicians and nurses with a structured approach to review problems that may have occurred

346. 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/overview-cuspmvp-facguide.docx
     January 01, 2017 - event—both staff and patients—what happened and what else was happening in the environment when the event occurred … As a group, consider all the reasons you think the failure occurred.

347. Overview of the Comprehensive Unit-based Safety Program for Application to Mechanically Ventilated Patients: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/modules/cusp/overview-cusp-mvp-facguide.html
     February 01, 2017 - event—both staff and patients—what happened and what else was happening in the environment when the event occurred … As a group, consider all the reasons you think the failure occurred.

348. 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/slides.html
     December 01, 2014 - AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention Facilitator Training Slide Presentation Text version of slide presentation. Slide 1: Overview of On-Time AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention Facilitator Training Overview of On-Time Slid…

349. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruprev/factraining_slides.pptx
     December 01, 2014 - PowerPoint Presentation AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention Facilitator Training Overview of On-Time On-Time Pressure Ulcer Prevention Facilitator Training 2-day training provides: Overview of On-Time Instruction on the role of a Facilitator Introduction to On-Time reports an…

350. Creating a Work-Around to Implement Fall Risk Screening For Older Adults Using Appointment Notes Case Study (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/opioids/compendium/opioids-case-study-work-around.pdf
     June 02, 2025 - to identify the patients at highest risk for an adverse event (i.e., fall) before a hospital event occurred

351. Job Aid: Presenting Performance Data (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/job-aid-presenting-data.pdf
     June 02, 2025 -  Show where particular events occurred that might have a positive or negative impact.

352. Limitations of AI and the Resulting Risk | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-ai-wave4.html
     July 01, 2025 - A widely publicized example occurred in 2023, when a lawyer submitted a legal brief drafted using ChatGPT

353. Final Progress Report: Improving Safety and Quality with Outpatient Order Entry (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/gandhi-report.pdf
     January 01, 2024 - Implementation of an EHR integrated with ACPOE and CDSS also occurred at three health centers affiliated … Implementation of the EHR’s full functionality occurred in stages over a 3-month period. … The implementation process occurred over a 3-month period. … Similarly, the Atrius EHR implementation occurred within a single health network that devoted significant

354. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/facslides.html
     September 01, 2017 - AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits Facilitator Training Slide Presentation Text version of slide presentation. Slide 1: Overview of On-Time AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department V…

355. AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention Facilitator Training | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/factraining-slides.html
     October 01, 2017 - AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention Facilitator Training Overview of On-Time Text version of slide presentation. Slide 1: Overview of On-Time AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention Facilitator Training Overview of On-Time Slide 2: On-Time Fall…

356. On-Time Pressure Ulcer Healing: Facilitator Training Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/facslides.html
     December 01, 2017 - On-Time Pressure Ulcer Healing: Facilitator Training Slide Presentation AHRQ’s Safety Program for Nursing Homes Text version of slide presentation. Slide 1: Overview of On-Time AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Healing Facilitator Training Slide 2: On-Time Pressure Ulcer…

357. Final Progress Report: Diagnostic Error in Dystonia (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/tanner-report.pdf
     January 01, 2025 - (c) How many and what types of inappropriate diagnostic tests and treatments occurred due to misdiagnosis … (d) How many misdiagnoses as a psychiatric disorder or as a malingerer occurred? … Excess visits primarily occurred in the 5 years prior to diagnosis; no further excess was observed when

358. Final Report: Translating simulation-based team leadership training into patient-level outcomes (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/fernandez-rosenman-report.pdf
     January 01, 2024 - pre-training performance, injury severity score, postgraduate training year, and days since training occurred … It is not entirely surprising that one third to one half of trauma patient-related errors occurred in … Additionally, because data collection occurred over a 2-year period, it is possible that this learning … As noted above, leader assessment occurred in a team setting. … Negative numbers indicated that baseline events occurred prior to the intervention date.

359. Final Progress Report: Improving Medication Safety Across Clinical Settings (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/bates-report.pdf
     January 01, 2024 - Data collection occurred for 8 to 10 weeks at each site. In total, 3680 patients were recruited. … home, where the medications were being obtained, and any symptoms or adverse events that may have occurred … rate, 50% of Rxs; 95% CI, 47%-53%) and 60% of the 464 near misses (rate, 12% of Rxs; 95% CI, 11%-14%) occurred … Serious, life-threatening, or fatal events occurred at a rate of 2.49 per 100 resident-months; … Errors resulting in preventable events occurred most often at the prescribing and monitoring

360. Module 4: Teamwork and Communication: Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module4/mod4-facguide.html
     March 01, 2017 - investigate and analyze it (for example, conduct a root cause analysis) to determine if resident harm occurred