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Showing results for "occurred".

21. TeamSTEPPS Specialty Scenarios: Dental (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/scenarios/dental.pdf
    March 19, 2014 - In this scenario, either of two actions should have occurred. … Had a brief or check-back occurred, they would have shared their individual situation awareness with

22. Best Practices in the Management of Patients With Antibiotic Allergies – Facilitator Guide (doc file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/allergies-guide.docx
    September 01, 2022 - specific symptoms that led to the diagnosis of the penicillin allergy, particularly when the reaction occurred … SAY: If the patient reports an allergy, ask how long after they started the antibiotic the reaction occurred … Also, ask how long ago the reaction occurred. … Ask her to describe what the rash looked like, how often after the first dose of antibiotics it occurred

23. Module 5: How To Measure Fall Rates and Fall Prevention Practices (doc file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module5/module5_fall-prevention.docx
    June 30, 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

24. Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Health Care November Meeting Summary (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/topics/fed-IWG-dxsafety-Nov19mtg.pdf
    November 15, 2019 - Workgroup Summary: The latest workgroup meeting occurred virtually on November 15, 2019, from 10 a.m

25. Chapter 2. Fall Response | Agency for Healthcare Research and Quality
    www.qualitymeasures.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

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

27. CAUTI Event Reporting Tool (doc file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/clabsi-event-reporting.docx
    April 01, 2022 - central lines in each nursing unit where this patient received care for the month in which the CLABSI occurred … rates for hand hygiene in each unit where this patient received care for the month in which the CLABSI occurred … line maintenance bundle for each unit on which the patient received care during the month the CLABSI occurred … variations happening on any of the units where the patient was located during the month in which the CLABSI occurred

28. Learning-From-Antibiotic-Adverse (doc file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/learning-from-antibiotic-adverse.docx
    June 01, 2021 - X Team Factors Example: Team discussion about need to start antibiotics occurred

29. CLABSI Learning From Defects Tool (doc file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/clabsi-learning-from-defects.docx
    April 01, 2022 - (Communication Plan) Now that you have more information about how and why this CLABSI occurred, how will

30. CAUTI Learning From Defects Tool (doc file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cauti-learning-from-defects.docx
    April 01, 2022 - (Communication Plan) Now that you have more information about how and why this CAUTI occurred, how will

31. New AHRQ SOPS™ Health Information Technology Patient Safety Supplemental Items for Hospitals - Optimizing (Gandhi) (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospital/healthitwebinar/sops-hit-webcast3-gandhi.pdf
    January 01, 2018 - Prevent errors and adverse events • Facilitating a more rapid response after an adverse event has occurred

32. Appendix B: Bringing It To Life - Case Study | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/health-literacy/professional-training/lepguide/app-b.html
    September 01, 2020 - This case highlights a situation that could have occurred in any hospital around the country. … The next level of missed opportunity occurred at the level of the triage nurse.

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

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

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

36. Sensemaking and Learn from Defects for Perinatal Safety (pdf file)
    www.qualitymeasures.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.

37. Pf-Engagement-Facilitator-Guide (doc file)
    www.qualitymeasures.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

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

39. TeamSTEPPS® Instructor Manual: Specialty Scenarios | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/teamstepps/instructor/scenarios/dental.html
    March 01, 2014 - In this scenario, either of two actions should have occurred. … Had a brief or check-back occurred, they would have shared their individual situation awareness with

40. Applying the AHRQ Quality Indicators to Hospital Data (pdf file)
    www.qualitymeasures.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