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Showing results for "occurred".

461. Serious Reportable Adverse Events in Health Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Kizer2.pdf
     December 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…

462. Final Progress Report: Crossing an Invisible Quality Chasm: From NICU to Ambulatory Care (pdf file)
     www.ahrq.gov/sites/default/files/2024-12/moyer-report.pdf
     January 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…

463. Final Progress Report: APPLIED STRATEGIES FOR IMPROVING PATIENT SAFETY (ASIPS) (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/pace-report.pdf
     January 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%

464. Federal Interagency Workgroup: Improving Diagnostic Safety and Quality in Healthcare July Meeting Summary (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/topics/IAWG-July-2024-meeting-notes.pdf
     January 01, 2024 - Workgroup Summary: The latest Workgroup meeting occurred virtually on July 26, 2024, and was attended

465. Impact of Staff-Led Safety Walk Rounds (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Montgomery_42.pdf
     March 05, 2008 - Results Safety walk rounds have occurred seven times between January and August 2007. … • Are you aware of any “near misses” – events that almost caused patient harm but didn’t – that occurred

466. AHRQ Safety Program for Perinatal Care: Rapid Response for Perinatal Safety: Rapid Response Systems (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/rapid-response/tool_rapidresponse-systems.docx
     May 01, 2017 - It also helps everyone understand why the event occurred and how it could be prevented in the future. … rapid response · Nature of assistance provided during response · Whether a debriefing with primary team occurred

467. Measure Descriptions for Daily Care Processes: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/modules/technical/dailycare-processes-facguide.html
     January 01, 2017 - physical or occupational therapist, and finally, whether any adverse events associated with mobilization occurred … and, if not, what types of events occurred.

468. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/dailycare-processes-facguide.docx
     January 01, 2017 - physical or occupational therapist, and finally, whether any adverse events associated with mobilization occurred … and, if not, what types of events occurred.

469. Science of Safety and Identifying Defects in Care of Mechanically Ventilated Patients: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/modules/cusp/science-of-safety-fac-guide.html
     February 01, 2017 - reporting systems, sentinel events, and claims data are reactive—the unfortunate event has already occurred

470. Transitional Care Medication Safety: Stakeholders' Perspectives | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/liability/corbett.html
     August 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.

471. Action-Plan-Template (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/action-plan-template.docx
     April 01, 2022 - Unit Action Plan The Comprehensive Unit-based Safety Program (CUSP) or healthcare-associated infection (HAI) leader is responsible for leading the CUSP team in completing an Action Plan in order to drive work related to lowering bloodstream infections (CLABSI) and/or catheter-associated urinary tract infections (CAUTI)…

472. Applying a Novel Organization Change Scale in a Multisite Patient Safety Initiative | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/liability/brock.html
     August 01, 2017 - Advances in Patient Safety and Medical Liability Applying a Novel Organization Change Scale in a Multisite Patient Safety Initiative Previous Page Next Page Table of Contents Advances in Patient Safety and Medical Liability Preface Acknowledgments Prologue Silence A Commentary Reforming th…

473. Acute Care Asymptomatic Bacteriuria and Urinary Tract Infections
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/allergies-slides.pptx
     September 01, 2022 - Acute Care Asymptomatic Bacteriuria and Urinary Tract Infections Best Practices in the Management of Patients With Antibiotic Allergies Ambulatory Care AHRQ Safety Program for Improving Antibiotic Use AHRQ Pub. No. 17(22)-0030 September 2022 Antibiotic Allergies AHRQ Safety Program for Improving Antibiotic Us…

474. Proactive Risk Assessment of Surgical Site Infections in Ambulatory Surgery Centers (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/stpra/stpra.pdf
     March 01, 2012 - care workers learn these strategies on the job, in the setting where a serious or sentinel event has occurred

475. NICU Family Information Packet, Appendix B, Growth (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-growth.pdf
     June 02, 2025 - NICU Family Information Packet, Appendix B, Growth Growth General Growth ■ Use growth charts made specifically for premature infants. ■ After infant reaches term corrected gestational age, a standard growth chart may be used. ■ Use corrected postmenstrual age until 2 years of age. ■ Interpretations of catch-u…

476. Selected Best Practices and Suggestions for Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d4i_pdi11-dehiscence-bestpractices.pdf
     May 17, 2016 - Selected Best Practices and Suggestions for Improvement Pediatric Toolkit for Using the AHRQ Quality Indicators How To Improve Hospital Quality and Safety 1 Tool D.4i Selected Best Practices and Suggestions for Improvement PDI 11: Postoperative Wound Dehiscence Why focus on postoperative wound dehiscence in…

477. Selected Best Practices and Suggestions for Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4w_combo_pdi11-dehiscence-bestpractices.pdf
     May 17, 2016 - Selected Best Practices and Suggestions for Improvement Toolkit for Using the AHRQ Quality Indicators How To Improve Hospital Quality and Safety 1 Tool D.4w Selected Best Practices and Suggestions for Improvement PDI 11: Postoperative Wound Dehiscence Why focus on postoperative wound dehiscence in children?…

478. Chapter 2. Analyze Care Delivery | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/vtguide/guide2.html
     February 01, 2016 - Preventing Hospital-Associated Venous Thromboembolism Chapter 2. Analyze Care Delivery Previous Page Next Page Table of Contents Preventing Hospital-Associated Venous Thromboembolism Preface Executive Summary Chapter 1. The Framework for Improvement Chapter 2. Analyze Care Delivery Chapter…

479. Chapter 2. Analyze Care Delivery | Agency for Healthcare Research and Quality
     www.ahrq.gov/es/patient-safety/settings/hospital/vtguide/guide2.html
     February 01, 2016 - Preventing Hospital-Associated Venous Thromboembolism Chapter 2. Analyze Care Delivery Previous Page Next Page Table of Contents Preventing Hospital-Associated Venous Thromboembolism Preface Executive Summary Chapter 1. The Framework for Improvement Chapter 2. Analyze Care Delivery Chapter…

480. 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.pdf
     July 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”