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Total Results: 2,792 records

Showing results for "occurred".

41. Final Progress Report: Developing biomechanical models from initiated fall actions and reactions in frail elderly patients (pdf file)
    www.ahrq.gov/sites/default/files/2024-07/morse-merryweather-report.pdf
    January 01, 2024 - The majority of FREs occurred in the Stand and Gait phases (n = 45 and 33, respectively). … Twenty-eight FREs occurred in Stand Preparation through the Stand Phase, FREr; 18 FREs occurred during … The shortest duration occurred in the Gait Initiation Subphase: 1.32 (0.58) seconds. … The majority of FREs occurred during rising. … The majority of the 61 FREs occurred during rising.

42. Final Progress Report: Blood Product Transfusion & Safe Practices (pdf file)
    www.ahrq.gov/sites/default/files/2024-02/herwaldt-report.pdf
    January 01, 2024 - Identification Errors 4/21/04 – 2/07/05 (Pilot Period) Prevented Errors Count Step/ Occurred Step … Skipped steps occurred when the nurse or phlebotomist failed to scan -10- the patient’s barcoded … Skipped steps often occurred because personnel within the Critical Care Laboratory failed to complete … Skipped steps during administration occurred when the transfusionist failed to complete all three scans … This occurred at night in an intensive care unit shortly after the system was activated.

43. Final Progress Report: Developing and Training Interruption Management Strategies for Emergency Physicians (pdf file)
    www.ahrq.gov/sites/default/files/2024-09/ratwani-report.pdf
    January 01, 2024 - tasks physicians were engaged in on a second-by-second basis and to document the when interruptions occurred … • The location of where the interruption occurred was recorded as being at the workstation, in the … Consequently, we could not observe any interruptions that occurred in patient rooms. … Rejecting interruptions occurred only 1.3% of the time (n = 6 occurrences). … source of the interruptions and the primary tasks that were being performed when the interruptions occurred

44. HAC National Scorecard 2014-16 (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac-scorecard-2014-16.pdf
    January 01, 2014 - HAC National Scorecard 2014-16 Between 2014-2016, 350,000 fewer hospital-acquired conditions (HACs) occurred

45. Chapter 9. Potential Future Uses of the Data Infrastructure | Agency for Healthcare Research and Quality
    www.ahrq.gov/practiceimprovement/delivery-initiative/ihs/chapter9.html
    December 01, 2017 - following the visit may be used to assess if laboratory testing, medication changes, and ECM service use occurred … If such service use occurred following the visit, the office visit may be classified as a clinical opportunity

46. Disclosure Checklist | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/checklist5.html
    August 01, 2022 - after the CANDOR event is identified, advise the patient and/or family that an adverse event may have occurred … Explain what is known about why the adverse event occurred; do not speculate.  

47. 023-Ss-Cusp-Learning-From-Defects-Fg (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/023-ss-cusp-learning-from-defects-fg.docx
    April 01, 2025 - Even if the MRSA detection represents colonization and no infections have occurred, this indicates an … infection prevention lapse occurred, and the patient is at increased risk of developing a MRSA infection … · What actions occurred? · What were people thinking and feeling? … · What else was happening at the time the defect occurred? … The CUSP team found that after implementing the interventions, no MRSA SSI infections occurred in the

48. AHRQ Mastectomy SB Infographic v15 (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/double-mastectomy.pdf
    February 01, 2016 - The rise in mastectomies occurred despite breast cancer rates remaining constant. 2005 2013 Sharp

49. Abt Single-Sided Body Template (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallpxsamplereports.docx
    June 02, 2025 - within the facility’s electronic medical record, such as nurse assessments, and represent changes that occurred … Summary of Fall Risk Factors Report is a count of risk factors associated with the falls that have occurred … For each month, it displays the number of falls that occurred and the risk factors associated with … each fall with fall date prior to and within 30 days of report date: Day of week on which the fall occurred … , Shift during which the fall occurred, Time at which the fall occurred, The location of the fall, and

50. PowerPoint Presentation
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module6/module6-care-for-caregiver.pptx
    May 01, 2011 - , but they feared that an error may have occurred. … /organization recognizing event occurred. … This stage is characterized by either the second-victim realizing that an event has occurred, or the … organization recognizing that an event has occurred. … The event might produce feelings of internal inadequacy, either because the event occurred or because

51. PowerPoint Presentation
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/module5-response-disclosure-notes.pptx
    August 21, 2015 - The patient and/or family have a reasonable expectation to be informed when a harm event has occurred … of this initial conversation is to advise the patient and/or family that an adverse event may have occurred … Investigation and Analysis, the disclosure should include – An explicit statement that an event has occurred … During disclosure, patients and families generally want a clear, explicit statement that an event has occurred … If the event was preventable and occurred due to error, the communicator should: Consider using the word

52. 111-Ss-Cusp-Lfd-Worksheet-A3 (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/111-ss-cusp-lfd-worksheet-a3.docx
    April 01, 2025 - Knee Joint Replacement, and Spinal Fusion SurgeriesOwner: ____________________________ Date Defect Occurred

53. 111-Cusp-Learning-From-Defects-Worksheet (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-surgery/111-cusp-learning-from-defects-worksheet.docx
    April 01, 2025 - Knee Joint Replacement, and Spinal Fusion SurgeriesOwner: ____________________________ Date Defect Occurred

54. Impact | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/cusp/clabsi-neonatal/nclabsi6.html
    January 01, 2013 - prevented, the number of actual CLABSIs reported are compared with the number of CLABSIs that would have occurred

55. Final Progress Report: Mining complex clinical data for patient safety research (pdf file)
    www.ahrq.gov/sites/default/files/2024-07/hripcsak-report.pdf
    January 01, 2024 - NLP successfully identified which of 45 NYPORTS events occurred in 57,452 discharge summaries, achieving … We also expected that it would often be unclear whether an error actually occurred. … If voluntary reporting occurred in the medical record, then this approach might reveal errors that would … The predictive value was best if the word occurred in the hospital course section of the discharge summary … detected conflicts in the medical record that might possibly signal that a medical adverse event has occurred

56. AHRQ Impact Case Studies Criteria | Agency for Healthcare Research and Quality
    www.ahrq.gov/news/newsroom/case-studies/criteria.html
    December 01, 2019 - Impact or results must have already occurred.

57. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/measuredesc-dailyearlymobility-facguide.docx
    January 01, 2017 - physical or occupational therapist, and finally, whether any adverse events associated with mobilization occurred … and, if so, what types of events occurred. … Slide 28 Events SAY: The next columns are designed to help track any adverse events that might have occurred … This field allows you to document up to three events if multiple events occurred. … Slide 29 Event Codes SAY: If no adverse events occurred, use “0” (the code for “none”) to indicate

58. Measure Descriptions for Daily Early Mobility: Facilitator Guide | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/mvp/modules/technical/daily-early-mobility-fac-guide.html
    February 01, 2017 - physical or occupational therapist, and finally, whether any adverse events associated with mobilization occurred … and, if so, what types of events occurred. … 29: Events Say: The next columns are designed to help track any adverse events that might have occurred … This field allows you to document up to three events if multiple events occurred. … Slide 30: Event Codes Say: If no adverse events occurred, use "0" (the code for "none") to indicate

59. Final Progress Report: Creating Learning Cultures Around Mistakes for Residents (pdf file)
    www.ahrq.gov/sites/default/files/2024-02/hoff-report.pdf
    January 01, 2024 - In addition, we looked for instances when errors or near misses occurred and how the interactions between … Regardless of setting, most errors occurred when the resident was alone. … Half (50%) of the 20 surgical resident mistakes and near misses occurred in isolation (i.e., no other … Surprisingly, in surgery’s case, 15 (75%) of the 20 mistakes and near misses occurred on the hospital … In the MICU case, although a higher percentage of mistakes occurred in isolation, 19 of the 21 mistakes

60. 68. For the Patient Willing To Quit (Continued) | Agency for Healthcare Research and Quality
    www.ahrq.gov/prevention/guidelines/tobacco/clinicians/presentations/2008update-full/slide68.html
    October 01, 2014 - If tobacco use has occurred, review circumstances and elicit recommitment to total abstinence.