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Total Results: 4,281 records

Showing results for "occurred".

41. Final Progress Report: Evaluation of Risk by Active Surveillance in the Emergency Department (ERASED) (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/17111-Hall-report.pdf
    September 01, 2007 - events were categorized into two taxonomies: (1) the segment of emergency care in which the event occurred … Patient visits were eligible for inclusion if (1) the visit occurred in the adult emergency department … An additional category, transitions, was added to account for periods when an event occurred during … The nonideal care events were categorized into the segment of care in which they occurred (Figure 1) … Significant time was spent distinguishing the true process from workarounds, which occurred between

42. Event Investigation and Analysis Guide: Appendix C | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/capacity/candor/modules/guide4/apc.html
    February 01, 2017 - This format helps to utilize the information found in the investigation to understand why the event occurred

43. 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

44. What Happens After a Patient Safety Event? Medical Expenditures and Outcomes in Medicare (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Encinosa.pdf
    January 01, 2003 - period the IOM report was released), we examine potentially preventable adverse medical events that occurred … The unit of observation was any major surgery admission (identified as the “index” surgery) that occurred … The surgeries occurred at 1,725 hospitals nationwide. … potentially preventable adverse medical events only cases in which the evidence that such an event occurred … Thus, there may have been many more preventable safety events (as well as close calls) that occurred

45. Appendix G. Safety and Adverse Events | Agency for Healthcare Research and Quality
    www.ahrq.gov/es/hai/universal-icu-decolonization/universal-icu-apg.html
    September 01, 2013 - difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue), but it has occurred

46. Final Progress Report: Pediatric Medication Safety: Analyses from the MEDMARX Medication Error Reporting System (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/bundy-report.pdf
    January 01, 2024 - Categories E through H errors not only occurred and reached the patient but also caused harm. … In one study of nationally representative US data, extra vaccination occurred in 21% of young children … Harmful errors occurred with all cardiovascular drug classes. … However, because over half the errors occurred at the administering stage of medication processing, … Not surprisingly, a large majority of reported pediatric antidepressant medication errors occurred

47. Adverse Drug Events occurring in U.S. Hospitals (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/adverse-drug-events.pdf
    July 02, 2015 - Adverse Drug Events occurring in U.S. Hospitals 0 10 20 30 40 50 60 70 80 Adverse Drug Events Occurring in U.S. Hospitals Adverse drug events (ADEs) are the most common nonsurgical adverse events that occur in hospitals. New data from all payers in 32 States in HCUP show characteristics of the four most frequent …

48. Final Progress Report: Medication Error Reduction, Technologies and Human Factors (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/carayon-report.pdf
    January 01, 2024 - The pump observations occurred 1 month before Smart IV pump implementation and 5 months 4 after … Forty-six hours of meeting time occurred over 4.5 months, representing 600 person-hours of time. … The second round of usability testing occurred with what was ultimately the final pump. … There were nine different units and the emergency department on which the observations occurred. … Staff were unaware and surprised that an UNDER- infusion most likely occurred in these cases.

49. 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

50. Final Progress Report: Brief, Risky, High-Benefit Procedures: Best Practice Model (pdf file)
    www.ahrq.gov/sites/default/files/2024-02/mackenzie-report.pdf
    January 01, 2024 - No operator injuries occurred with a redesigned instrument tray. … Complications of CTI in one study of 426 consecutive patients occurred in 21%. … Undrained pneumothorax, hemothorax, or effusion despite CTI occurred in 35 patients. … In one of these patients, the air re-accumulation occurred after hospital discharge. … In one patient, this occurred 5 days after hospital discharge (Fig. 5).

51. AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention Training | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/reportguide.html
    November 01, 2017 - It displays the number of falls that occurred and the risk factors associated with the falls. … For each of the months (1 or 3) included in the report, any fall that occurred before the report date … For each of the months (1 or 3) included in the report, any fall that occurred before the report date … For each of the months (1 or 3) included in the report, any fall that occurred before the report date … , Shift during which the fall occurred, Time at which the fall occurred, The location of the fall

52. The Nature, Characteristics and Patterns of Perinatal Critical Events Teams (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Riley_58.pdf
    April 02, 2008 - to execute a specific task, whereas “team reformation” occurred when team membership changed in a … Each behavioral marker was scored using the following scale: • “0” Behavior occurred at or below … • “2” Behavior occurred more than 90 percent of the times when prompted by the event set. … emergency measures; and planning for an emergency intervention occurred. … Leadership transfer occurred continuously throughout an obstetrics emergency.

53. A Fresh Look at the Data Shows Patient Safety Improving Overall, With Improvement Still Needed in Many Areas | Agency for Healthcare Research and Quality
    www.ahrq.gov/news/blog/ahrqviews/fresh-look-at-ptsafety-data.html
    October 01, 2018 - These gains and others show where progress has occurred.  … a reminder that in many areas where quality improvement efforts are gaining ground, success has not occurred

54. AHRQ-Funded Program Helps Long-Term Care Provider Reduce Falls | Agency for Healthcare Research and Quality
    www.ahrq.gov/news/newsroom/case-studies/cdom0604.html
    October 01, 2014 - collection had shown BHRS administrators that half of the residents had only one fall and most falls occurred … In addition, most falls occurred within the first few weeks of admission.

55. 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

56. An Analysis of Nurses' Cognitive Work: A New Perspective for Understanding Medical Errors (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Potter.pdf
    January 01, 2003 - The total number of links was summarized and grouped, then the number of activities that occurred for … Calculations were made to show the cognitive load at the time each interruption occurred and at the … Omissions for RN #3 occurred with a cognitive stacking load of 16, 18, 17, and 16 respectively. … Omissions occurred at various times with respect to a nurse’s cognitive stacking measure. … For example, an omission occurred with a nurse’s cognitive stacking as low as 5 and as high as 20.

57. Preparing for Ambulatory Computerized Prescriber Order Entry by Evaluating Preimplementation Medication Errors (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Devine.pdf
    July 01, 2003 - , but the medication did not reach the patient C An error occurred that reached the patient but did … but no patient harm Error, harm E An error occurred that resulted in the need for treatment or … hospitalization and caused temporary patient harm G An error occurred that resulted in permanent … patient harm H An error occurred that resulted in a near-death event (e.g., anaphylaxis, cardiac … A 5-month time frame was identified; in an effort to minimize bias, one that occurred immediately prior

58. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits - Functional Specifications (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallspxspecs.pdf
    February 01, 2018 - type occurred daily. … type occurred daily. … type occurred daily. … type occurred daily. … type occurred daily.

59. 5. How do you measure fall rates and fall prevention practices? | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/measure-fall-rates.html
    January 01, 2013 - With each fall, you will need to define the level of injury that occurred, if any. … The patient in whom the fall occurred. The date the fall occurred. … But for calculation of a fall rate, you need the date the fall occurred and the responsible unit (if … Rates are calculated as follows: First, count the number of falls that occurred during the month … Try to understand why the fall occurred and how such an incident might be prevented in the future.

60. Improving the Safety of Heparin Administration by Implementing a Human Factors Process Analysis (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Harder.pdf
    May 19, 2003 - Brennan et al.1 reported that adverse events occurred in 3.7 percent of the selected cases (95% confidence … Thomas et al.2 reported that in this sample, adverse events occurred at a rate of 2.9 percent (with … Death occurred in 6.6 percent (SD of 1.2 percent) of the adverse events. … in 2003.4 Not surprisingly, the results of the studies of adverse events that occurred in Utah and … This education occurred on the patient care units 24 hours a day for the 5-day process.