Results

Total Results: 2,792 records

Showing results for "occurred".

361. Patient and Family Engagement | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/modules/patient-family-engagement/notes.html
     September 01, 2013 - investigate and analyze it (e.g., a root cause analysis may be conducted) to determine if patient harm occurred

362. Making the Case That Improving Antibiotic Use Is a Patient Safety Issue (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/patient-safety-facilitator-guide.pdf
     November 01, 2019 - For 25 percent of patients, these events occurred after hospital discharge. … Step 2 SAY: A second issue occurred when another clinician in the practice decided to treat the

363. 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/factraining.html
     September 01, 2017 - high risk or had a recent change in risk, would we do things differently to intervene before the event occurred … they were for potentially preventable conditions, the time of day and day of week that the transfers occurred

364. Improving the Safety of Diagnosis and Therapy in the Inpatient Setting | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/learning-lab/improving-safety-diagnosis-long-desc.html
     February 01, 2024 - process failures (DPFs) in a cohort of representative cases. 1 Most of the significant DPFs (63.3%) occurred

365. Chapter 5 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/chapter5.html
     August 01, 2022 - The event itself: the type of event; where (in the process of care) and when it occurred; who was involved … (functions, not names); why it occurred (most dominant cause); and risk assessment (including event

366. Antibiotic-Targets-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/antibiotic-targets-facilitator-guide.docx
     June 01, 2021 - Several opportunities for improvement occurred in this case of a resident with an uncomplicated cystitis … We discussed several opportunities that occurred in this case when we walked through the Four Moments

367. From Here to There: Lessons from an Integrative Patient Safety Project in Rural Health Care Settings (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Cook.pdf
     January 01, 2004 - failure to communicate), the health care providers were hesitant to acknowledge that an error had occurred … to nursing, an overwhelming majority of the respondents indicated that they believed an error had occurred … appropriate treatment: Only about two-thirds of our respondents indicated that they believe an error had occurred

368. Using Probabilistic Risk Assessment to Model Medication System Failures in Long-term Care Facilities (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Comden.pdf
     January 01, 2003 - combinations of elements that might operate to produce the same outcome—they can only describe what occurred

369. Module 3: Script and Slides (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/problem-solving/problem-solving-facnotes.docx
     May 01, 2017 - [1: ] Often, it is appropriate to apply type 2 problem solving to understand why the problem occurred

370. Module 3: Problem Solving and Escalation - Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/management/problem-solving-fac-notes.html
     June 01, 2017 - Often, it is appropriate to apply type 2 problem solving to understand why the problem occurred and then

371. Outpatient Surgery and Patient Safety—The Patient’s Voice (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Hundt.pdf
     January 01, 2003 - These questions addressed issues such as when the symptom first occurred, whether the participant called … The first attempt to conduct the survey occurred at least 7 days postoperative. … symptom the participant experienced, we asked more detailed questions concerning when the symptom occurred … Regardless of when the symptoms occurred, 88 percent (n = 141) of the symptoms were believed by participants

372. Implementing Shared Decision-Making: Barriers and Solutions—An Orthopedic Case Study | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/liability/mincer.html
     August 01, 2017 - Methods After approval by our institutional review board (IRB), an implementation process occurred … These trainings occurred over a 3-week training period and were done in the clinic to decrease additional … shown on the pocket reminder card, were posted in locations where surgeon and patient interactions occurred … These coaching sessions were short, focused sessions that occurred in the clinic immediately following

373. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/fallpxoverview.pptx
     October 01, 2017 - PowerPoint Presentation AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention Facilitator Training Overview of On-Time On-Time Falls Prevention Facilitator Training 2-day training provides: Overview of On-Time. Instruction on the role of a Facilitator. Introduction to On-Time reports and implementation…

374. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-factraining-slides.pptx
     November 01, 2016 - PowerPoint Presentation AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Healing Facilitator Training Overview of On-Time On-Time Pressure Ulcer Healing Facilitator Training Two-day training provides: Overview of On-Time. Instruction on the role of a Facilitator. Introduction to On-Time reports and …

375. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/ontime-preventablehospitaledvisits-overview.pptx
     May 01, 2017 - PowerPoint Presentation AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits Facilitator Training Overview of On-Time On-Time Preventable Hospital and ED Visits Facilitator Training 2-day training provides: Overview of On-Time. Instruction on the role of a Facilita…

376. Final Progress Report: Interactive HIT to promote ambulatory safety among vulnerable diabetes patients (pdf file)
     www.ahrq.gov/sites/default/files/2024-11/sarkar-report.pdf
     January 01, 2024 - Results: Overall, there were 360 safety triggers that occurred among 155 participants, which represented … Whenever a safety trigger occurred throughout the course of the intervention, protocol instructed a … adverse events among patients taking high-risk medications16 and after hospital discharge.17 Triggers occurred

377. Half-Day Training Content | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps-program/curriculum/intro/teach/half-day.html
     August 01, 2023 - Either in small groups or as a class, ask participants to discuss: What breakdowns in teamwork occurred

378. The 2022 National Healthcare Quality and Disparities Report: We Still Have Much Work to Do | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/blog/ahrqviews/2022-national-healthcare-disparities-report.html
     November 01, 2022 - Significant improvements have occurred for people receiving care at home.

379. Contributions to Patient Safety and Medical Liability | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/demo-program/grants/contributions.html
     August 01, 2022 - guidelines for outpatient primary care practice staff on how to communicate with patients after an error has occurred

380. Efficiency Gains with Computerized Provider Order Entry (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Steele_100.pdf
     March 18, 2008 - Absolute reductions in TAT occurred in all three departments, with decreases of 79 minutes for laboratory … Similar to our study, their largest improvements occurred in medication TATs, which can potentially