Results

Total Results: 2,959 records

Showing results for "occurred".

401. Improving the Safety of Diagnosis and Therapy in the Inpatient Setting | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/learning-lab/improving-safety-diagnosis-long-desc.html
     February 01, 2024 - process failures (DPFs) in a cohort of representative cases. 1 Most of the significant DPFs (63.3%) occurred

402. Final Progress Report: Diagnostic Error in Dystonia (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/tanner-report.pdf
     January 01, 2025 - (c) How many and what types of inappropriate diagnostic tests and treatments occurred due to misdiagnosis … (d) How many misdiagnoses as a psychiatric disorder or as a malingerer occurred? … Excess visits primarily occurred in the 5 years prior to diagnosis; no further excess was observed when

403. Final Report: Translating simulation-based team leadership training into patient-level outcomes (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/fernandez-rosenman-report.pdf
     January 01, 2024 - pre-training performance, injury severity score, postgraduate training year, and days since training occurred … It is not entirely surprising that one third to one half of trauma patient-related errors occurred in … Additionally, because data collection occurred over a 2-year period, it is possible that this learning … As noted above, leader assessment occurred in a team setting. … Negative numbers indicated that baseline events occurred prior to the intervention date.

404. Final Progress Report: Improving Medication Safety Across Clinical Settings (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/bates-report.pdf
     January 01, 2024 - Data collection occurred for 8 to 10 weeks at each site. In total, 3680 patients were recruited. … home, where the medications were being obtained, and any symptoms or adverse events that may have occurred … rate, 50% of Rxs; 95% CI, 47%-53%) and 60% of the 464 near misses (rate, 12% of Rxs; 95% CI, 11%-14%) occurred … Serious, life-threatening, or fatal events occurred at a rate of 2.49 per 100 resident-months; … Errors resulting in preventable events occurred most often at the prescribing and monitoring

405. 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/pruprev/care/resources/ontime/pruprev/saworksheet.html
     December 01, 2017 - readmission ___ With a change in condition ___ With each MDS assessment ___ When weight loss has occurred

406. Antibiotic-Targets-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/antibiotic-targets-facilitator-guide.docx
     June 01, 2021 - Several opportunities for improvement occurred in this case of a resident with an uncomplicated cystitis … We discussed several opportunities that occurred in this case when we walked through the Four Moments

407. Saworksheet (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruprev/saworksheet.docx
     June 02, 2025 - .  When weight loss has occurred e.  Change in meal intake f.  Change in fluid intake g.  Change

408. TeamSTEPPS Team Leadership Module 2
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/curriculum/teamstepps-module-2-slides.pptx
     June 02, 2025 - skills Designed to improve outcomes: An accurate recounting of key events Analysis of why the event occurred

409. Contributions to Patient Safety and Medical Liability | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/demo-program/grants/contributions.html
     August 01, 2022 - guidelines for outpatient primary care practice staff on how to communicate with patients after an error has occurred

410. Half-Day Training Content | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps-program/curriculum/intro/teach/half-day.html
     August 01, 2023 - Either in small groups or as a class, ask participants to discuss: What breakdowns in teamwork occurred

411. The 2022 National Healthcare Quality and Disparities Report: We Still Have Much Work to Do | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/blog/ahrqviews/2022-national-healthcare-disparities-report.html
     November 01, 2022 - Significant improvements have occurred for people receiving care at home.

412. AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/factraining.html
     November 01, 2017 - high risk or had a recent change in risk, would we do things differently to intervene before the event occurred … Fall Risk Factors Report provides information regarding the number and percentage of falls that have occurred

413. 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

414. 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.

415. 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

416. 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…

417. Outpatient Surgery and Patient Safety—The Patient’s Voice (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Hundt.pdf
     January 01, 2003 - These questions addressed issues such as when the symptom first occurred, whether the participant called … The first attempt to conduct the survey occurred at least 7 days postoperative. … symptom the participant experienced, we asked more detailed questions concerning when the symptom occurred … Regardless of when the symptoms occurred, 88 percent (n = 141) of the symptoms were believed by participants

418. Implementing Shared Decision-Making: Barriers and Solutions—An Orthopedic Case Study | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/liability/mincer.html
     August 01, 2017 - Methods After approval by our institutional review board (IRB), an implementation process occurred … These trainings occurred over a 3-week training period and were done in the clinic to decrease additional … shown on the pocket reminder card, were posted in locations where surgeon and patient interactions occurred … These coaching sessions were short, focused sessions that occurred in the clinic immediately following

419. 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

420. Efficiency Gains with Computerized Provider Order Entry (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Steele_100.pdf
     March 18, 2008 - Absolute reductions in TAT occurred in all three departments, with decreases of 79 minutes for laboratory … Similar to our study, their largest improvements occurred in medication TATs, which can potentially