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Total Results: 2,792 records

Showing results for "occurred".

381. AHRQ Safety Program for Perinatal Care: Facilitation Instructions for Conducting In Situ Simulations
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/situ/simulation.pptx
     May 01, 2017 - 6 Scenarios for Simulation Simulation scenarios can be designed to replay real events that have occurred … Video review is extremely helpful in allowing the participants to see exactly what communication occurred

382. Best Practices in the Diagnosis and Treatment of Clostridioides difficile Infections (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/best-practices/CDI-facilitator-guide.pdf
     November 01, 2019 - Moments of Antibiotic Decision Making SAY: Moment 2 reminds us to ensure appropriate testing has occurred … It spanned over a decade, so other changes that occurred during this time period may have impacted … In addition, improvements in infection control practices occurred.

383. Validation of AHRQ’s Patient Safety Indicator for Accidental Puncture or Laceration (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Gallagher1.pdf
     January 01, 2004 - medical record reviews using a standard validation review instrument to determine if a reportable event occurred … analyzed to determine if the potential APL, as defined using the AHRQ APL definition, was an event that occurred … Several primary procedures occurred at a high frequency and were used for this analysis.

384. Program Implementation | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/clabsi-final/clabsifinal2.html
     January 01, 2013 - The kick-off meeting occurred approximately 1-3 months after the immersion calls, the mid-course meeting

385. Examples of How States Use Quality Measures | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/quality-resources/tools/chtoolbx/measures/measure-8.html
     December 01, 2017 - Public reporting has encouraged HMOs to focus on performance improvement and sustained improvement has occurred

386. Appendix 1-A. Suggested Slides for Module 1 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/gdmod1a.html
     October 01, 2014 - See if a change occurred in any of the resident's other vital signs.

387. Measure: Cesarean Delivery for Nulliparous (NTSV) Women (Appropriate Use) (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/chipra_1415-p009-5-ef.pdf
     May 01, 2013 - substantial variation by State and hospital.1,2 ● Overall, nearly a third of all births (32.8 percent) occurred

388. Measure: Pediatric Lower Respiratory Infection (LRI) Readmission Measure (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/chipra_1415-p008-2-ef.pdf
     January 01, 2015 - Most index hospitalizations occurred at hospitals whose readmission rate reliability was at least 0.7

389. Measure: Pediatric All-Condition Readmission Measure (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/chipra_14-p008-1-ef.pdf
     October 01, 2014 - Most index hospitalizations occurred at hospitals with a readmission rate reliability of at least 0.7

390. 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/overviewhandouts2.html
     December 01, 2017 - readmission ___ With a change in condition _X_ With each MDS assessment ___ When weight loss has occurred

391. 144-Cusp-Tip-Sheet-Engaging-Surgeons (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/144-cusp-tip-sheet-engaging-surgeons.docx
     April 01, 2025 - CUSP Tip Sheet: Engaging Surgeons in MRSA and SSI Prevention Surgical Services For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries Issue1-5 Surgeons play crucial roles in quality and safety, as leaders, champions, committee members, and participants in planning and executing change. Each role is …

392. Chapter 2. Determine Surgical Site Infection Rates (continued) | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/ssi/ssi2a.html
     April 01, 2018 - Three surgeries were missed because the SSI occurred greater than 30 days postoperatively. … Both occurred in total hip arthroplasties with onset of infection greater than 30 days postoperatively … All of this information occurred after discharge from the initial surgery.

393. Appendix A, Pt. 2 | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/stpra/stpraapa2.html
     April 01, 2018 - In 12 patients (80%), the infection occurred after a rotator cuff repair. … Knee pain, swelling, and warmth always occurred, but erythema was noted in only 30% of patients. … Results This study is based on 462 prosthetic join infections that occurred in 460 of 26,499 patients

394. Implement Teamwork and Communication: | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/modules/implement/teamwork-notes.html
     December 01, 2012 - Exercise Do: Think of a defect that occurred on your unit because of a communication breakdown. … An analysis of why an event occurred, what worked, and what did not work,. … This tool provides physicians and nurses a structured approach to review problems that may have occurred

395. Beyond Rapid Response Teams: Instituting a “Rover Team” Improves the Management of At-Risk Patients, Facilitates Proactive Interventions, and Improves Outcomes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Hueckel_27.pdf
     April 01, 2008 - to PRRT/Rover implementation (July 2005 – February 2006), an average of one non-ICU pediatric Code occurred … Approximately 40 percent (115/291) of interactions occurred during the Rover Team’s scheduled rounds … has been reported that, during a 6-year study period, a greater number of readmissions to the PICU occurred

396. Saworksheet (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruprev/saworksheet.docx
     June 02, 2025 - .  When weight loss has occurred e.  Change in meal intake f.  Change in fluid intake g.  Change

397. TeamSTEPPS Team Leadership Module 2
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/curriculum/teamstepps-module-2-slides.pptx
     June 02, 2025 - skills Designed to improve outcomes: An accurate recounting of key events Analysis of why the event occurred

398. Defining Diagnostic Error: A Scoping Review to Assess the Impact of the National Academies’ Report Improving Diagnosis in Health Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/topics/defining-diagnostic-error-a-scoping-review.pdf
     April 27, 2022 - diagnosis later turned out to be wrong (e.g., a case in which an undesirable diagnostic outcome had occurred … Missed elevated BP occurred when a provider failed to document an appropriate action for a patient with … assumed diagnosis later turned out to be wrong (i.e., in which an undesirable diagnostic outcome had occurred … or commission (doing something wrong) exists at the particular point in time at which the “error” occurred … In the articles that did include the NASEM definition (n = 52), most mentions occurred in the in- troduction

399. AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/factraining.html
     November 01, 2017 - high risk or had a recent change in risk, would we do things differently to intervene before the event occurred … Fall Risk Factors Report provides information regarding the number and percentage of falls that have occurred

400. 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/care/resources/ontime/pruprev/saworksheet.html
     December 01, 2017 - readmission ___ With a change in condition ___ With each MDS assessment ___ When weight loss has occurred