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Showing results for "occurred".

21. Chapter 2. Fall Response | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man2.html
    December 01, 2017 - Unless there is evidence suggesting otherwise, the most logical conclusion is that a fall has occurred … distance to the next lower surface (in this case, the floor) is not a factor in determining whether a fall occurred … , an immediate intervention should be put in place by the nurse during the same shift that the fall occurred

22. AHRQ Impact Case Studies Criteria | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/news/newsroom/case-studies/criteria.html
    December 01, 2019 - Impact or results must have already occurred.

23. Summary (Instructor Guide) (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module7/ts2-0ltc_module7_ig_summary.pdf
    May 10, 2017 - • Identify the instances where a breakdown in teamwork has occurred as it relates to the specific … Scenario A gastrointestinal outbreak has occurred within the nursing home and has affected the entire … – A better handoff would have occurred.

24. Module 5: How To Measure Fall Rates and Fall Prevention Practices—Training Guide | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-5/guide.html
    September 01, 2017 - When the fall occurred. What the degree of injury was, if any. … First, count the number of falls that occurred during the month from your incident reporting system. … Try to understand why the fall occurred and how such an incident might be prevented in the future. … individual data points are plotted and then connected (as shown by the blue line) to show that they occurred … However, it also shows a breakdown of the fall rate by the different types of falls that occurred—anticipated

25. Federal Interagency Workgroup on Improving Diagnostic Safety--March Meeting Summary (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/topics/DxSafety-March2019-MeetingNotes.pdf
    March 08, 2019 - Workgroup Summary: The workgroup meeting occurred on March 8, 2019, and was attended by representatives

26. Learn-From-Defects-Facilitator-Guide (doc file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.docx
    May 01, 2017 - the event or issue by providing teams the tools and resources needed to make sense of a failure that occurred … happen—No-harm event Event did not reach the patient—Near-miss event We then ask why this consequence occurred … Try to view the world as they did when the event occurred. 2. Why did it happen? Step 1.

27. Sensemaking and Learn from Defects for Perinatal Safety (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.pdf
    May 01, 2017 - event or issue by providing teams the tools and resources needed to make sense of a failure that occurred … Perinatal Care Sensemaking & Learn From Defects 10 miss event We then ask why this consequence occurred … Try to view the world as they did when the event occurred. 2. Why did it happen? • Step 1.

28. Pf-Engagement-Facilitator-Guide (doc file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/pf-engagement-facilitator-guide.docx
    May 01, 2017 - Generally, only findings that are reasonably certain to have occurred and unlikely to change should be … investigate and analyze it (e.g., a root cause analysis may be conducted) to determine whether patient harm occurred

29. Sensemaking and Learn From Defects for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-fac-guide.html
    July 01, 2023 - the event or issue by providing teams the tools and resources needed to make sense of a failure that occurred … We then ask why this consequence occurred. … Try to view the world as they did when the event occurred. Why did it happen? Step 1.

30. Applying the AHRQ Quality Indicators to Hospital Data (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/b1_combo_applyingqis.pdf
    March 01, 2016 - for that specific indicator Observed events = for each QI indicator, the total sum of events that occurred … observed rate (also called the raw rate) is the actual rate at which events measured by the indicator occurred … probability that a particular indicator event will occur based on the frequency with which the event occurred … (Note that a lower rate for a PSI signifies better performance because fewer adverse events have occurred

31. Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Health Care (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/topics/public-notes-meeting-summary-110620.pdf
    March 11, 2021 - Workgroup Summary: The latest Workgroup meeting occurred virtually on November 6, 2020, from 1 p.m.

32. Federal Interagency Workgroup on Improving Diagnostic Safety and Quality (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/topics/public-notes-meeting-summary-031121.pdf
    July 22, 2021 - Workgroup Summary: The latest Workgroup meeting occurred virtually on March 11, 2021, from 10 a.m. to

33. Tool: I-PASS | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/teamstepps-program/curriculum/communication/tools/ipass.html
    July 01, 2023 - to support a patient are prepared for situations they might not have considered before the handoff occurred

34. 2023 National Healthcare Quality and Disparities Report (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2023-nhqdr-es-rev.pdf
    January 01, 2023 - ■ The change in racial and ethnic diversity has occurred largely in younger age groups. … The slowdown occurred after passage of several federal COVID-19-related bills, which included temporary … This was due, in part, to the emergence of more transmissible variants of the virus, which occurred … • Most COVID-19 deaths occurred among adults age 65 and over. … But large numbers of deaths also occurred among adults ages 50-64 and 18-49, especially during surges

35. Development and Validation of the Medication Administration Error Reporting Survey (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Wakefield2.pdf
    January 01, 2003 - First, by definition, recognition that an error has occurred means that the error happened some time … Because of this, recognition that an error has occurred is very difficult.20 Second, even if an error … activities leading to patients receiving medication, they are often “blamed” for errors that may have occurred … When errors occur, they are likely to be viewed as failures of character (i.e., the error occurred … • Nurses do not recognize an error occurred. • Medication error is not clearly defined.

36. Event Investigation and Analysis Guide: Appendix C | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apc.html
    August 01, 2022 - This format helps to utilize the information found in the investigation to understand why the event occurred

37. Silence A Commentary | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/patient-safety/reports/liability/silence.html
    August 01, 2017 - There are four things patients and families want after medical harm has occurred: tell us what happened … after medical harm. 5 I believe there is a fifth desire for some patients and families after harm has occurred

38. Implementation Planning | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/teamstepps-program/curriculum/implement/activity/plan.html
    February 01, 2024 - Measure before and after you implement TeamSTEPPS to see whether the desired changes occurred.

39. Section 8: The Care Management Evidence Base (continued) | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/medicaidmgmt/mm8a.html
    October 01, 2014 - quality of life improved significantly at 6 months, whereas at 12 months, no significant improvement occurred … symptoms were reduced significantly, but at 12 months, no significant change in asthma symptoms had occurred … Similarly, the same study found that after 2 weeks, no differences occurred in asthma planning visits … same study found that after two weeks, no differences in asthma planning visits or acute care visits occurred

40. Adverse Drug Events Occurring in U.S. Hospitals | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/data/infographics/adverse-drug-events.html
    August 01, 2018 - Skip to main content An official website of the Department of Health and Human Services Careers Contact Us Español FAQs Search all AHRQ sites Search small Search Menu …