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Showing results for "occurred".

21. Module 5: How To Measure Fall Rates and Fall Prevention Practices—Training Guide | Agency for Healthcare Research and Quality
    www.innovations.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

22. Federal Interagency Workgroup on Improving Diagnostic Safety--March Meeting Summary (pdf file)
    www.innovations.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

23. Sensemaking and Learn from Defects for Perinatal Safety (pdf file)
    www.innovations.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.

24. Pf-Engagement-Facilitator-Guide (doc file)
    www.innovations.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

25. Sensemaking and Learn From Defects for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
    www.innovations.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.

26. Applying the AHRQ Quality Indicators to Hospital Data (pdf file)
    www.innovations.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

27. Table 5.A.1. Evidence Table (pdf file)
    www.innovations.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-143-section-5a-evidence-table.pdf
    January 01, 2014 - Medical records flagged with an alert were reviewed to determine whether an ADE had occurred. … Whenever a trigger occurred, the data management system automatically sent an alert, leading reviewers … The majority of AEs occurred in the neonatal intensive care unit (13.4 AEs per 1000 patient-days; … , and if it had occurred, the event’s preventability and severity. … Chart reviews occurred in a 2-stage process.

28. Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Health Care (pdf file)
    www.innovations.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.

29. Federal Interagency Workgroup on Improving Diagnostic Safety and Quality (pdf file)
    www.innovations.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

30. Tool: I-PASS | Agency for Healthcare Research and Quality
    www.innovations.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

31. Event Investigation and Analysis Guide: Appendix C | Agency for Healthcare Research and Quality
    www.innovations.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

32. Silence A Commentary | Agency for Healthcare Research and Quality
    www.innovations.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

33. Adverse Drug Events Occurring in U.S. Hospitals | Agency for Healthcare Research and Quality
    www.innovations.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 …

34. Engage Patients and Families for Perinatal Safety (pdf file)
    www.innovations.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/pf-engagement-facilitator-guide.pdf
    May 01, 2017 - Generally, only findings that are reasonably certain to have occurred and unlikely to change should … investigate and analyze it (e.g., a root cause analysis may be conducted) to determine whether patient harm occurred

35. System-Focused Event Investigation and Analysis Guide | Agency for Healthcare Research and Quality
    www.innovations.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4.html
    August 01, 2022 - If a normal error has occurred, the provider undoubtedly feels bad and should be supported. … technology, the information, and the processes are all critical clues to the context in which the event occurred … the context is best done through observations of normal work flow in the environment where the event occurred … It is an opportunity for everyone to understand the event, why it occurred, and confirm contributing

36. CHIPRA 123: Technical Specifications (pdf file)
    www.innovations.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/availability/chipra-0123-technical-specifications.pdf
    October 18, 2019 - CALCULATION Step 1: Identify all deliveries that occurred in medical facilities, using the criteria …                                                                Step 8: Count the number of high risk deliveries that occurred

37. Technical Specifications: High-Risk Deliveries at Facilities with 24/7 In-House Physician Coverage Dedicated to the Obstetrical Service by an Anesthesiologist Who Is Qualified to Provide Obstetrical Anesthesia (pdf file)
    www.innovations.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/availability/chipra-121-technicalspecs.pdf
    January 31, 2020 - CALCULATION Step 1: Identify all deliveries that occurred in medical facilities, using the criteria … Step 8: Count the number of high risk deliveries that occurred in Class 1 and Class 2 facilities for

38. Reviewing the Team's Performance: Debrief | Agency for Healthcare Research and Quality
    www.innovations.ahrq.gov/teamstepps-program/curriculum/team/tools/debrief.html
    December 01, 2023 - Analysis of why the event occurred, what worked, and what did not work.

39. Impact of AHRQ’s Patient Safety Tools: Challenge Competition | Agency for Healthcare Research and Quality
    www.innovations.ahrq.gov/patient-safety/about/challenge-competition.html
    February 01, 2024 - The most visible advances occurred in the services and nursing units (a 50% reduction in general surgery

40. Tool: STAR | Agency for Healthcare Research and Quality
    www.innovations.ahrq.gov/teamstepps-program/curriculum/situation/tools/star.html
    June 01, 2023 - members are asked to respond to a change in a patient’s status when expected improvements have not occurred