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Total Results: 2,792 records

Showing results for "occurred".

401. Final Progress Report: Real-time assessment of risk factors for medication errors (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/dresselhaus-report.pdf
     January 01, 2024 - Sampling occurred during all work hours, although residents were able to turn the computer off during … The sign-on surveys occurred at the beginning of each day and queried subjects regarding type of call

402. Post-fielding Surveillance of a Guideline-based Decision Support System (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Chan.pdf
     January 01, 2004 - describing the actions of the program were recorded in text files, including any program exceptions that occurred … the NASA space shuttle Challenger accident concluded that “a disproportionate reduction may have occurred

403. Final Progress Report: HIV/HCV Support Team to Improve Medication Safety and Engagement in Care (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/berry-report.pdf
     January 01, 2024 - Despite universal electronic decision support at our hospital, ART errors occurred in 30% of hospitalizations … In a recent case at Hopkins Hospital, rebound occurred after 6 days of an incomplete regimen. … In 2013, 927 (58%) of 1,609 total hospitalizations of PLWH at Hopkins Hospital occurred on the HIV/AIDS … A total of 145 ART errors occurred in 110 (29%) hospitalizations. … As above, about half of admissions of PLWH to Hopkins Hospital historically occurred on the HIV specialty

404. Prioritization Worksheet (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/c1_pdi_prioritizationworksheetinstructions.pdf
     June 02, 2025 - Ideally, if your data permit, consider only costs that occur after the adverse event occurred.

405. Prioritization Worksheet (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheetinstructions.pdf
     June 02, 2025 - Ideally, if your data permit, you would consider only costs that occur after the adverse event occurred

406. Better Nurse Staffing Levels Associated With Lower Rates of Cesarean Section | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsletters/e-newsletter/945.html
     February 01, 2025 - of Psychiatry , used MEPS data to identify the disparities in access to mental telehealthcare that occurred

407. Antibiotic Stewardship Helps Protect Newborns in Neonatal Intensive Care Units | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsletters/e-newsletter/939.html
     November 01, 2024 - Publications must have occurred between July 1, 2022, and June 30, 2024.

408. SOPS® Medical Office Survey Data Submission Is Open September 2–19 | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsletters/e-newsletter/972.html
     August 01, 2025 - The result of virtual conversations with stakeholders that occurred in March 2025, the publication includes

409. Join the IDEAS Project To Advance Diagnostic Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsletters/e-newsletter/966.html
     July 01, 2025 - diverse roles and hospital settings, eliciting a total of 60 diagnostically challenging incidents that occurred

410. 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

411. Error Producing Conditions in the Intensive Care Unit (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Drews_15.pdf
     February 26, 2008 - Root causes, which represent the fundamental reasons why the event occurred, are investigated by analyzing … how and why the event occurred. … understanding of what the event reveals about systemic problems in the health care organization in which it occurred

412. 066-Dec-Staff-Faqs-Safety-Side-Effects (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/066-dec-staff-faqs-safety-side-effects.docx
     October 01, 2024 - AHRQ Safety Program for MRSA Prevention Decolonization: Staff Frequently Asked Questions Safety & Side Effects This document provides questions and answers to commonly asked questions. Some questions and answers may not be relevant to your unit. You should remove or edit information to match your unit’s protocols. The…

413. Implementing Safety Cultures in Medicine: What We Learned by Watching Physicians (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Hoff.pdf
     January 01, 2003 - In surgery, these types of mistakes often occurred in the act of operating directly on patients, while … Just 3 of the 26 (12 percent) MICU team mistakes and near misses occurred in a group care situation, … (i.e., where others on the team could witness the mistake or near miss as it occurred). … Half of the 20 surgery team resident mistakes and near misses occurred in isolation, (i.e., where no … Surprisingly, 15 of 20 (75 percent) surgery team mistakes and near misses occurred on the hospital floor

414. Final Progress Report: Safety Advancement in the Emergency Department (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/hall2-report.pdf
     January 01, 2024 - Nurses voiced their concern about the decline in communication that has occurred as a result of the … The participants would be asked to comment on their experience of nonideal care events that occurred

415. Appendix B. Clinical Materials to Share With Primary Care Providers | Agency for Healthcare Research and Quality
     www.ahrq.gov/es/patient-safety/settings/hospital/resource/nicu/packet/apb.html
     December 01, 2013 - Transitioning Newborns from NICU to Home Appendix B. Clinical Materials to Share With Primary Care Providers Previous Page Next Page Table of Contents Transitioning Newborns from NICU to Home A Resource Toolkit Basic Components of the Health Coach Program Family Information Packet Cover Sheet …

416. Appendix B. Clinical Materials to Share With Primary Care Providers | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/resource/nicu/packet/apb.html
     December 01, 2013 - Transitioning Newborns from NICU to Home Appendix B. Clinical Materials to Share With Primary Care Providers Previous Page Next Page Table of Contents Transitioning Newborns from NICU to Home A Resource Toolkit Basic Components of the Health Coach Program Family Information Packet Cover Sheet …

417. 1 Preventablehospitaledvisits-Overview-Ig (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/1_preventablehospitaledvisits-overview-ig.pdf
     June 02, 2025 - 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

418. Pressure Ulcer Prevention Toolkit (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module4/putoolkit_module4_tools.docx
     January 01, 1995 - Pressure Ulcer Prevention Toolkit Pressure Ulcer Prevention Toolkit Module 4 Tools 2G: Pieper Pressure Ulcer Knowledge Test 4A: Assigning Responsibilities for Using Best Practice Bundle with the left column completed (by the Implementation Team Leader/co-leaders and best practices decided upon earlier by the team 4B:…

419. AHRQ Tribal Consultation Policy | Agency for Healthcare Research and Quality
     www.ahrq.gov/cpi/about/mission/strategic-plan/tribal-consultation-policy.html
     August 01, 2014 - AHRQ Tribal Consultation Policy Consultation plan to ensure input by tribal officials in development of regulatory and other policies with substantial direct effects on one or more tribes. Each Federal department must have a process to ensure meaningful and timely input by tribal officials in development of r…

420. Why Should Your Practice Focus on Improving Antibiotic Prescribing? – Facilitator Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/antibiotic-prescribing-guide.docx
     September 01, 2022 - From the time the patient presented for medical care to the time harm occurred, there were several opportunities