Results

Total Results: 2,959 records

Showing results for "occurred".

441. Final Progress Report: Developing Definitions, Measurement Strategies, and Links to Medication Errors (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/savage-report.pdf
     January 01, 2024 - Examples of this frequently occurred when nurses worked around the process by “borrowing” another patient

442. Beyond Rapid Response Teams: Instituting a “Rover Team” Improves the Management of At-Risk Patients, Facilitates Proactive Interventions, and Improves Outcomes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Hueckel_27.pdf
     April 01, 2008 - to PRRT/Rover implementation (July 2005 – February 2006), an average of one non-ICU pediatric Code occurred … Approximately 40 percent (115/291) of interactions occurred during the Rover Team’s scheduled rounds … has been reported that, during a 6-year study period, a greater number of readmissions to the PICU occurred

443. Implement Teamwork and Communication: | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/modules/implement/teamwork-notes.html
     December 01, 2012 - Exercise Do: Think of a defect that occurred on your unit because of a communication breakdown. … An analysis of why an event occurred, what worked, and what did not work,. … This tool provides physicians and nurses a structured approach to review problems that may have occurred

444. Chapter 2. Determine Surgical Site Infection Rates (continued) | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/ssi/ssi2a.html
     April 01, 2018 - Three surgeries were missed because the SSI occurred greater than 30 days postoperatively. … Both occurred in total hip arthroplasties with onset of infection greater than 30 days postoperatively … All of this information occurred after discharge from the initial surgery.

445. Appendix A, Pt. 2 | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/stpra/stpraapa2.html
     April 01, 2018 - In 12 patients (80%), the infection occurred after a rotator cuff repair. … Knee pain, swelling, and warmth always occurred, but erythema was noted in only 30% of patients. … Results This study is based on 462 prosthetic join infections that occurred in 460 of 26,499 patients

446. Tool 1: Readmission Data Analysis and Interpretation (xls file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/mcaidread_tool1_data_analysis_final.xlsx
     June 02, 2025 - discharges for a given 1-year period, less exclusions listed below • Numerator: all hospitalizations that occurred

447. AHRQ Quality and Safety Review System (QSRS) | Agency for Healthcare Research and Quality
     www.ahrq.gov/cpi/about/otherwebsites/qsrs.ahrq.gov/index.html
     March 01, 2021 - AHRQ Quality and Safety Review System (QSRS) Mission AHRQ has developed and tested an improved patient safety surveillance system to replace the Medicare Patient Safety Monitoring System (MPSMS). The new system is known as the Quality and Safety Review System (QSRS). The QSRS relies on clinical information re…

448. 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

449. Defining Diagnostic Error: A Scoping Review to Assess the Impact of the National Academies’ Report Improving Diagnosis in Health Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/topics/defining-diagnostic-error-a-scoping-review.pdf
     April 27, 2022 - diagnosis later turned out to be wrong (e.g., a case in which an undesirable diagnostic outcome had occurred … Missed elevated BP occurred when a provider failed to document an appropriate action for a patient with … assumed diagnosis later turned out to be wrong (i.e., in which an undesirable diagnostic outcome had occurred … or commission (doing something wrong) exists at the particular point in time at which the “error” occurred … In the articles that did include the NASEM definition (n = 52), most mentions occurred in the in- troduction

450. Candor-Impguide (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/candor-impguide.pdf
     April 01, 2016 - Investigation and Analysis has been completed, which will take place within 30-45 days after the event occurred

451. AHRQ National Scorecard on Hospital-Acquired Conditions: Updated Baseline Rates and Preliminary Results 2014-2017 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/hacreport-2019.pdf
     January 01, 2019 - reductions seen in 2015, 2016, and 2017 compared with 2014, AHRQ estimates a total of 910,000 fewer HACs occurred … That means approximately 1.8 million fewer HACs would occur compared with the number that would have occurred … for 2018, and 2019 as the data become available. 12 Due to the transition from ICD-9 to ICD-10 that occurred … the number of events (HACs) for the full year of 2015. 13 Due to the ICD-9 to ICD-10 transition that occurred … discharges, i.e., the number of HACs shown in 2015–2017 is based on the number of HACs that would have occurred

452. Chapter 6. Discussion and Policy Implications | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/chapter6.html
     August 01, 2022 - Designing Consumer Reporting Systems for Patient Safety Events Chapter 6. Discussion and Policy Implications Previous Page Next Page Table of Contents Designing Consumer Reporting Systems for Patient Safety Events Executive Summary Chapter 1. Background Chapter 2. Conceptual Framework and Desi…

453. NICU Family Information Packet, Appendix B, Sleep in Preterm Infants (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-sleep.pdf
     June 02, 2025 - NICU Family Information Packet, Appendix B, Sleep in Preterm Infants Sleep in Preterm Infants SIDS ■ Preterm infants are known to be at higher risk for SIDS; high-risk period lasts up to 10 months. ■ To reduce risk: – Use supine positioning on a firm mattress with no fluffy or loose bedding. – Be sure the in…

454. Risk-Based Patient Safety Metrics (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Scanlon_62.pdf
     March 25, 2008 - Additionally, an injury occurred that might be measured—i.e., the cardiac arrest.

455. Enabling Real-Time Identification of Burnout Risk Among Clinicians in Primary Care Practices | Agency for Healthcare Research and Quality
     www.ahrq.gov/ncepcr/about/impact-stories/enabling-real-time.html
     April 01, 2025 - Enabling Real-Time Identification of Burnout Risk Among Clinicians in Primary Care Practices AHRQ Impact: Researchers have developed a prediction tool to identify primary care practices at high-risk of clinician burnout. Instead of relying on clinician surveys that increase burden, the tool enables…

456. 152-Cusp-Tip-Sheet-Engaging-Physicians (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/152-cusp-tip-sheet-engaging-physicians.docx
     October 01, 2024 - AHRQ Safety Program for MRSA Prevention CUSP Tip Sheet: Engaging Physicians in MRSA Prevention ICU & Non-ICU Issue1-5 Physicians play crucial roles in quality and safety, as leaders, champions, committee members, and participants in planning and executing change. Each role is vital in the success of any undertaking to…

457. NICU Family Information Packet, Appendix B, Anemia of Prematurity (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-anemia.pdf
     June 02, 2025 - NICU Family Information Packet, Appendix B, Anemia of Prematurity Anemia Of Prematurity Characteristics ■ Occurs during the normal developmental switch from fetal to adult hemoglobin synthesis. ■ Immediately after birth, the increase in blood oxygen content results in the downregulation of erythropoietin. ■ On…

458. Meeting Minutes, May 2022 | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/events/nac/2022-05-nac/nacmtg051222-minutes.html
     August 01, 2022 - AHRQ has been working with healthcare systems throughout the nation, where consolidation has occurred … AHRQ could seek to determine lessons learned from the COVID era with respect to policy changes that occurred

459. Rapid Response for Perinatal Safety: Rapid Response Systems | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/rapid-response/tool-rapid-response-systems.html
     July 01, 2023 - It also helps everyone understand why the event occurred and how it could be prevented in the future. … Whether a debriefing with primary team occurred. Action items from debriefings.

460. 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/factraining.html
     December 01, 2014 - high risk or had a recent change in risk, would we do things differently to intervene before the event occurred