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Total Results: 2,959 records

Showing results for "occurred".

41. 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).

42. 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

43. 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.

44. 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

45. 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.

46. 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

47. 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.

48. Module 4: Event Reporting, Event Investigation and Analysis | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes4.html
    August 01, 2022 - information, other than event reports, that might provide information indicating that a CANDOR event has occurred … create a cohesive environment for informing the organization as to whether a CANDOR event may have occurred … implement the best practice of creating a hotline for staff to call when they feel a CANDOR event has occurred … Risk Management can also provide ongoing support to managers on the unit(s) where the event occurred. … Also, the location where the event occurred is generally no longer intact, so information that could

49. Module 5: Response and Disclosure | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/notes.html
    August 01, 2022 - 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 … During disclosure, patients and families generally want a clear, explicit statement that an event has occurred … what happened in a way that is easy to understand, explain what is known about why the adverse event occurred … If the event was preventable and occurred due to error, the communicator should: Consider using

50. 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.

51. 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

52. 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.

53. 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.

54. 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

55. 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

56. 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.  

57. 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

58. 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

59. 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

60. Module 6: Care for the Caregiver | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes6.html
    August 01, 2022 - , but they feared that an error may have 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 second-victim might not be able provide care in the room where the event occurred and might appear … The event might produce feelings of internal inadequacy, either because the event occurred or because