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Showing results for "occurred".
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes4.htmlAugust 01, 2022 - information, other than event reports, that might provide information indicating that a CANDOR event has occurred … create a cohesive environment for informing the organization as to whether a CANDOR event may have occurred … implement the best practice of creating a hotline for staff to call when they feel a CANDOR event has occurred … Risk Management can also provide ongoing support to managers on the unit(s) where the event occurred. … Also, the location where the event occurred is generally no longer intact, so information that could
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/notes.htmlAugust 01, 2022 - The patient and/or family have a reasonable expectation to be informed when a harm event has occurred … of this initial conversation is to advise the patient and/or family that an adverse event may have occurred … During disclosure, patients and families generally want a clear, explicit statement that an event has occurred … what happened in a way that is easy to understand, explain what is known about why the adverse event occurred … If the event was preventable and occurred due to error, the communicator should: Consider using
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/16774-Bundy-draft-1.pdfSeptember 29, 2009 - Categories E through H errors not only occurred and reached the patient but also caused harm. … In one study of nationally representative US data, extra vaccination occurred in 21% of young children … Harmful errors occurred with all cardiovascular drug classes. … However, because over half the errors occurred at the administering stage of medication processing, … Not surprisingly, a large majority of reported pediatric antidepressant medication errors occurred
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module6/module6-care-for-caregiver.pptxMay 01, 2011 - , but they feared that an error may have occurred. … /organization recognizing event occurred. … This stage is characterized by either the second-victim realizing that an event has occurred, or the … organization recognizing that an event has occurred. … The event might produce feelings of internal inadequacy, either because the event occurred or because
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/14253-Carayon-draft-1.pdfDecember 01, 2006 - The pump observations occurred 1 month before Smart IV pump implementation and 5 months 4 after … Forty-six hours of meeting time occurred over 4.5 months, representing 600 person-hours of time. … The second round of usability testing occurred with what was ultimately the final pump. … There were nine different units and the emergency department on which the observations occurred. … Staff were unaware and surprised that an UNDER- infusion most likely occurred in these cases.
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/checklist5.htmlAugust 01, 2022 - after the CANDOR event is identified, advise the patient and/or family that an adverse event may have occurred … Explain what is known about why the adverse event occurred; do not speculate.
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www.ahrq.gov/sites/default/files/2024-09/ratwani-report.pdfJanuary 01, 2024 - tasks physicians were engaged in on a second-by-second basis and to document the when interruptions occurred … • The location of where the interruption occurred was recorded as being at the workstation, in the … Consequently, we could not observe any interruptions that occurred in patient rooms. … Rejecting interruptions occurred only 1.3% of the time (n = 6 occurrences). … source of the interruptions and the primary tasks that were being performed when the interruptions occurred
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www.ahrq.gov/sites/default/files/2024-02/herwaldt-report.pdfJanuary 01, 2024 - Identification Errors 4/21/04 – 2/07/05 (Pilot Period) Prevented Errors Count Step/ Occurred Step … Skipped steps occurred when the nurse or phlebotomist failed to scan -10- the patient’s barcoded … Skipped steps often occurred because personnel within the Critical Care Laboratory failed to complete … Skipped steps during administration occurred when the transfusionist failed to complete all three scans … This occurred at night in an intensive care unit shortly after the system was activated.
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111-Ss-Cusp-Lfd-Worksheet-A3 (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/111-ss-cusp-lfd-worksheet-a3.docxApril 01, 2025 - Knee Joint Replacement, and Spinal Fusion SurgeriesOwner: ____________________________ Date Defect Occurred -
111-Cusp-Learning-From-Defects-Worksheet (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-surgery/111-cusp-learning-from-defects-worksheet.docxApril 01, 2025 - Knee Joint Replacement, and Spinal Fusion SurgeriesOwner: ____________________________ Date Defect Occurred -
www.ahrq.gov/sites/default/files/2024-07/morse-merryweather-report.pdfJanuary 01, 2024 - The majority of FREs occurred in the Stand and Gait phases (n = 45 and 33, respectively). … Twenty-eight FREs occurred in Stand Preparation through the Stand Phase, FREr; 18 FREs occurred during … The shortest duration occurred in the Gait Initiation Subphase: 1.32 (0.58) seconds. … The majority of FREs occurred during rising. … The majority of the 61 FREs occurred during rising.
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www.ahrq.gov/prevention/guidelines/tobacco/clinicians/presentations/2008update-full/slide68.htmlOctober 01, 2014 - If tobacco use has occurred, review circumstances and elicit recommitment to total abstinence.
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www.ahrq.gov/hai/cusp/clabsi-neonatal/nclabsi6.htmlJanuary 01, 2013 - prevented, the number of actual CLABSIs reported are compared with the number of CLABSIs that would have occurred
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www.ahrq.gov/news/newsroom/case-studies/criteria.htmlDecember 01, 2019 - Impact or results must have already occurred.
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023-Ss-Cusp-Learning-From-Defects-Fg (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/023-ss-cusp-learning-from-defects-fg.docxApril 01, 2025 - Even if the MRSA detection represents colonization and no infections have occurred, this indicates an … infection prevention lapse occurred, and the patient is at increased risk of developing a MRSA infection … · What actions occurred? · What were people thinking and feeling? … · What else was happening at the time the defect occurred? … The CUSP team found that after implementing the interventions, no MRSA SSI infections occurred in the -
www.ahrq.gov/rural-post-partum-challenge/about/faq.htmlJuly 01, 2020 - If a success story occurred in both urban and rural areas, is this eligible? … If it occurred in both a rural and an urban area then technically it is eligible, but for the purposes
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www.ahrq.gov/practiceimprovement/delivery-initiative/ihs/chap6tab25.htmlDecember 01, 2017 - ECM visit 2.6 2.8 3.7 3.4 4.5 3.0 a Diabetes education visits are visits that occurred
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes6.htmlAugust 01, 2022 - , but they feared that an error may have occurred. … This stage is characterized by either the second-victim realizing that an event has occurred, or the … organization recognizing that an event has occurred. … The second-victim might not be able provide care in the room where the event occurred and might appear … The event might produce feelings of internal inadequacy, either because the event occurred or because
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/module5-response-disclosure-notes.pptxAugust 21, 2015 - The patient and/or family have a reasonable expectation to be informed when a harm event has occurred … of this initial conversation is to advise the patient and/or family that an adverse event may have occurred … Investigation and Analysis, the disclosure should include – An explicit statement that an event has occurred … During disclosure, patients and families generally want a clear, explicit statement that an event has occurred … If the event was preventable and occurred due to error, the communicator should: Consider using the word
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www.ahrq.gov/teamstepps-program/curriculum/communication/tools/ipass.htmlJuly 01, 2023 - to support a patient are prepared for situations they might not have considered before the handoff occurred
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