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Showing results for "occurred".

381. 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

382. Health Care Simulation to Advance Safety: AHRQ Issue Brief (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/simulation-brief.pdf
     February 01, 2015 - The learning that occurred as a result of the simulation reveals opportunities for organizations to

383. 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

384. 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…

385. 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 …

386. 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…

387. 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

388. 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

389. 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

390. 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

391. Patient, Family Member, and Clinician Perceptions of Disclosure of Adverse Events in Labor and Delivery | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/liability/baker.html
     August 01, 2017 - discussion about disclosure and what patients and families preferred clinicians to disclose when a mistake occurred

392. 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

393. 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

394. 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.

395. 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

396. 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 …

397. 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.

398. 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.

399. 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

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