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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.monahrq.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.monahrq.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. Learn-From-Defects-Facilitator-Guide (doc file)
    www.monahrq.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.

24. Sensemaking and Learn from Defects for Perinatal Safety (pdf file)
    www.monahrq.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.

25. Pf-Engagement-Facilitator-Guide (doc file)
    www.monahrq.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

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

27. Applying the AHRQ Quality Indicators to Hospital Data (pdf file)
    www.monahrq.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

28. Table 5.A.1. Evidence Table (pdf file)
    www.monahrq.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.

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

31. Tool: I-PASS | Agency for Healthcare Research and Quality
    www.monahrq.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

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

33. Silence A Commentary | Agency for Healthcare Research and Quality
    www.monahrq.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

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

35. Leading Teams (Instructor Guide) (pdf file)
    www.monahrq.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module4/ts2-0ltc_module4_ig_lead.pdf
    May 10, 2017 - When emergencies have occurred at these events in the past, many people come running and there is … include: • Accurate recounting and documentation of key events; • Analysis of why the event occurred … • Recap the situation, background, and key events that occurred. … • Accurate recounting and documentation of key events; • Analysis of why the event occurred, what worked

36. Engage Patients and Families for Perinatal Safety (pdf file)
    www.monahrq.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

37. System-Focused Event Investigation and Analysis Guide | Agency for Healthcare Research and Quality
    www.monahrq.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

38. 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.monahrq.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

39. CHIPRA 123: Technical Specifications (pdf file)
    www.monahrq.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

40. Reviewing the Team's Performance: Debrief | Agency for Healthcare Research and Quality
    www.monahrq.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.