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Showing results for "occurred".
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www.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/chapter6.htmlAugust 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…
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152-Cusp-Tip-Sheet-Engaging-Physicians (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/152-cusp-tip-sheet-engaging-physicians.docxOctober 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… -
www.ahrq.gov/ncepcr/about/impact-stories/enabling-real-time.htmlApril 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…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-sleep.pdfJune 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…
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www.ahrq.gov/sites/default/files/2024-02/pace-report.pdfJanuary 01, 2024 - provided detailed information concerning the incident, the patient, and the context in which the incident occurred … events 8 were associated with no known harm; for 7.7% of reports, it was too early to tell if harm occurred … base a review of claims activity (both before and after the event) to determine if any medical error occurred … Mistakes occurred in a variety of settings. … Other errors occurred in nursing homes (10.3%), emergency departments (13.8%), and pharmacies (10.3%
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/factraining.htmlDecember 01, 2014 - high risk or had a recent change in risk, would we do things differently to intervene before the event occurred
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www.ahrq.gov/sites/default/files/wysiwyg/topics/IAWG-July-2024-meeting-notes.pdfJanuary 01, 2024 - Workgroup Summary: The latest Workgroup meeting occurred virtually on July 26, 2024, and was attended
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-anemia.pdfJune 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…
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www.ahrq.gov/patient-safety/reports/liability/corbett.htmlAugust 01, 2017 - contextual and complex, but they agreed that full disclosure was desired when an error that caused harm occurred … The case studies were based on actual medication discrepancies that occurred during a hospital-to-home … Now, let’s consider the reason each of those contributing factors have occurred.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Kizer2.pdfDecember 01, 2000 - Serious Reportable Adverse Events in Health Care 339 Serious Reportable Adverse Events in Health Care Kenneth W. Kizer, Melissa B. Stegun Abstract Health care errors resulting in patient harm are a leading cause of morbidity and mortality in the United States, although there is no national reporting of such…
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www.ahrq.gov/hai/tools/mvp/modules/cusp/science-of-safety-fac-guide.htmlFebruary 01, 2017 - reporting systems, sentinel events, and claims data are reactive—the unfortunate event has already occurred
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www.ahrq.gov/sites/default/files/2024-12/moyer-report.pdfJanuary 01, 2024 - Final Progress Report: Crossing an Invisible Quality Chasm: From NICU to Ambulatory Care AHRQ Grant Final Progress Report Title: Crossing An Invisible Quality Chasm: From NICU to Ambulatory Care Principal Investigator: Virginia A. Moyer, MD, MPH Team Members: Papile, Lucille A., MD, Co-Investigator Guillory, Char…
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Standardizing Ambulatory Care Procedures in a Public Hospital System to Improve Patient Safety (pdf file)
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Kleinpeter.pdfJanuary 01, 2004 - Training of residents occurred over a 90-day period, and this process was incorporated in the general … This procedure relocation occurred during a time of limited surgical schedules and increasing surgical … medical injury and medical errors focus on identification of the problem after harm or injury has occurred -
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Gavin.pdfJanuary 01, 2001 - This occurred for three of the items for one or more pair of raters indicating no problem with knees … condition/symptom is of low prevalence, the kappa may be calculated as a negative value.15, 16 This occurred … as a cut point to warrant further intervention, the authors acknowledge that some false positives occurred
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www.ahrq.gov/research/findings/final-reports/environmental-scan-programs/envscan-program2.htmlApril 01, 2018 - Level 2 Participant Learning— evaluates the extent to which learning has occurred as a result of training … categories: Setting of care— the location where the case took place or the facility in which the error occurred … As a result, if the environmental scan and abstraction occurred at a different time in the 3-year SOW
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-intro.htmlNovember 01, 2014 - The first visits occurred between November 2009 and May 2010, while the second visits occurred between … , one of the prospective projects had not begun data collection, and the second site visits had not occurred
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www.ahrq.gov/patient-safety/reports/liability/crane.htmlAugust 01, 2017 - potential for patient harm) and how to use the system to report these events as close to when they occurred … had access to the entire database, but the coders were blinded to the practice where the error had occurred … correlating the total of 770 near-miss reports we collected during the study with the number of AEs that occurred
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What Exactly Is Patient Safety? (pdf file)
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Emanuel-Berwick_110.pdfJuly 02, 2008 - revered profession with a privileged 4 relationship to society, but in part, it also may have occurred … Breaches in safety may have occurred in many blunt-end components, and as described above, events constitute … The analysis of what went wrong when an adverse event has occurred is known as “root cause analysis” -
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallpxoverview-ig.pdfJune 02, 2025 - risk or had a recent change in risk, would we do things differently to intervene before the event occurred … Risk Factors Report provides information regarding the number and percentage of falls that have occurred
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Puh-Factraining-Guide (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-factraining-guide.docxJune 02, 2025 - high risk or had a recent change in risk, would we do things differently to intervene before the event occurred
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