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Total Results: 2,792 records

Showing results for "occurred".

81. Facilitator Guide: Learning From Defects Through Sensemaking (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects_facnotes.docx
    December 01, 2017 - So, first look at the system and analyze why the mistake occurred. … What actions occurred? What were the team members thinking and feeling? … SAY: These are the types of questions to ask to understand how a defect occurred. … Try to find out exactly how things occurred in real time. Slide 13 What Happened? … No timeouts or debriefings occurred. NOTE: Spend 10 to 15 minutes discussing the case.

82. Module 1: Communication and Optimal Resolution (CANDOR) Toolkit Module 1: An Overview of the CANDOR Process
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/module1-overview.pptx
    June 02, 2025 - understand what a CANDOR event is and what to do when they recognize that a CANDOR event is occurring or has occurred … Activity: List de-identified events that have occurred in your organization. … Once activated, the CANDOR Response Team will work with the caregivers where the event occurred to ensure

83. Accessible Facilitator Guide: Learn From Defects for Sustainability (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_learn_from_defects_facnotes.docx
    December 01, 2017 - ASK: What if the same situation occurred on a different shift? … SAY: When a defect has already occurred, ask your frontline staff. … ASK: How do all these pieces lead to this error or the event that occurred? … If you can, simulate the defect, particularly for a defect that has occurred. … SAY: If a contributing factor is a major reason why the defect occurred, place that factor in the top

84. Sustainability: Learning From Defects: Facilitator Notes | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/surgery/modules/sustainability/learn-from-defects-fac-notes.html
    December 01, 2017 - Ask: What if the same situation occurred on a different shift? … Say: When a defect has already occurred, ask your frontline staff. … Ask: How do all these pieces lead to this error or the event that occurred? … If you can, simulate the defect, particularly for a defect that has occurred. … Say: If a contributing factor is a major reason why the defect occurred, place that factor in the top

85. An Overview of the CANDOR Process
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4/module4-event-reporting-investigation-analysis.pptx
    September 10, 2015 - 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

86. Introduction | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-pediatric-safety-1.html
    August 01, 2023 - focus of pediatric research, particularly in tertiary children’s hospitals. 6-11 Less exploration has occurred

87. Conclusion | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-5.html
    June 01, 2023 - situations that pose the greatest challenges for patients and families to reliably assess what has occurred

88. PowerPoint Presentation: Best Practices in the Diagnosis and Treatment of Community-Associated Lower Respiratory Tract Conditions
    www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/best-practices/respiratory-slides.pptx
    November 01, 2019 - Treat as community-acquired pneumonia if the event occurred within 72 hours of admission to a healthcare … Treat as healthcare-associated pneumonia if the event occurred after 72 hours of admission to a healthcare … antibiotics without improvement within 48 hours: Treat as community-acquired pneumonia if the event occurred … Treat as healthcare-associated pneumonia if the event occurred after 72 hours of admission to a health

89. Final Progress Report: Analysis of Factors Associated With Clinical Checklist Compliance (pdf file)
    www.ahrq.gov/sites/default/files/2024-05/sarcevic-report.pdf
    January 01, 2024 - “Now” activations occurred in 9% of digital checklist cases. … False checks occurred for 29 of the 32 tasks and accounted for 16% of all checked items. … Of all true-checks, 15% occurred before the team started performing a task. … Sixteen percent of all true checks occurred as the corresponding tasks were being performed. … Post-check occurred when the check-off timestamp occurred after the end time of the corresponding task

90. Appendix A. Recommendations for Ideal Consumer Reporting Systems | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/reports/hotline/appa.html
    May 01, 2016 - The system should capture both objective information about what occurred and more-subjective information … Information collected from consumers should include where a patient safety event occurred; what contributed

91. Premortem Tool | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/mvp/modules/cusp/premortem-tool.html
    January 01, 2017 - "Spend the next 10 minutes writing down all the reasons you believe this failure occurred. … Please spend the next 10 minutes writing down all the reasons you believe this failure occurred.

92. Tool: Premortem (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/premortem-tool.docx
    January 01, 2017 - · “Spend the next 10 minutes writing down all the reasons you believe this failure occurred. … Please spend the next 10 minutes writing down all the reasons you believe this failure occurred.

93. Board Checklist | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/cusp/toolkit/board-checklist.html
    December 01, 2012 - Discuss major patient safety events/errors that have occurred in the most recent timeframe to show that

94. Final Progress Report: Risk Analysis of Pediatric Chemotherapy Processes (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/shenep-report.pdf
    January 01, 2024 - Current controls almost always detect the failure. 2 Very slight effect Actual error occurred … Good likelihood that current controls will detect. 4 Minor effect Actual error occurred. … Review effectiveness of 80%. 5 Moderate effect Actual error occurred and reached the patient … Review effectiveness of 50%. 7 Major effect Actual error occurred and reached the patient. … Page 8 8 Extreme effect/major injury Actual error occurred and reached the patient.

95. Table 26. Utilization of education and case management service by type of visit among adults with diabetes who had at least one visit. Fiscal year 2010 | Agency for Healthcare Research and Quality
    www.ahrq.gov/practiceimprovement/delivery-initiative/ihs/chap6tab26.html
    December 01, 2017 - 33.1% 36.7% 3.8% 9.3% 100.0% 38.9% a Diabetes education visits are visits that occurred

96. AHRQ Safety Program for Perinatal Care: Board Checklist (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/supporting/board-checklist.docx
    May 01, 2017 - Discuss major patient safety events/errors that have occurred in the most recent timeframe to show that

97. Does Medical Error Disclosure Violate the Medical Malpractice Insurance Cooperation Clause? (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Banja.pdf
    January 01, 2004 - medical error, which is morally required of physicians when they know that a harm-causing error has occurred … ethically required to inform the patient of all the facts necessary to ensure understanding of what has occurred … Jones, an error occurred in your care that was responsible for the harm you experienced, and we apologize … An example of this occurred in Royston Moore v. … health professionals to desist from admitting liability when they know that harm-causing error has occurred

98. PowerPoint Presentation: Learn From Defects for Sustainability
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_learn_from_defects.pptx
    December 01, 2017 - ASK: What if the same situation occurred on a different shift? … SAY: When a defect has already occurred, ask your frontline staff. … ASK: How do all these pieces lead to this error or the event that occurred? … If you can, simulate the defect, particularly for a defect that has occurred. … What actions occurred? What were care team members thinking and feeling?

99. Tool: STAR | Agency for Healthcare Research and Quality
    www.ahrq.gov/teamstepps-program/curriculum/situation/tools/star.html
    July 01, 2024 - members are asked to respond to a change in a patient's status when expected improvements have not occurred

100. Mod01-Grand-Rounds-Slides (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/grandrounds/mod01-grand-rounds-slides.pdf
     April 01, 2016 - An explicit statement that an error occurred. 2. … The Investigation: to determine how the event occurred, and how to mitigate that event or even prevent … This is a cornerstone of the CANDOR process of investigating the root cause of how an error occurred … disclosure is a process, and the first step is to: ■ Let the patient and family know an adverse event occurred … result of the investigation and analysis of Michelle’s case, the following patient safety changes occurred