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Total Results: over 10,000 records

Showing results for "occurred".

121. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44760/psn-pdf
     July 10, 2024 - strategy to improve respectful and effective discussions with patients and families after harm has occurred

122. Medication Overdose | PSNet
     psnet.ahrq.gov/web-mm/medication-overdose
     September 01, 2011 - ADE), and an additional 5% experience a potential ADE (ie, the error reached the patient, but no harm occurred … reported similar rates of ADEs, though rates of potential ADEs were even higher.( 5 ) Most potential ADEs occurred … illegible, can have life-threatening consequences.( Figure 1 , Figure 2 ) The error in this case occurred … confusion between ‘dose’ and ‘day,’ due to ambiguous use of the abbreviation “d” in “mg/kg/d,” could have occurred … and ensures that orders are complete and in a standard format, eliminating ambiguous dosing orders as occurred

123. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/72713/psn-pdf
     February 03, 2021 - information to individuals that contact the organization for help when they feel an error may have occurred

124. Section5 3 (pdf file)
     hcup-us.ahrq.gov/reports/factsandfigures/2007/pdfs/section5_3.pdf
     January 01, 2007 - For stays with Medicare as the primary payer, in-hospital deaths occurred in 4 percent of stays. … Three percent of uninsured discharges occurred against medical advice, compared to less than 1 percent

125. Boardchecklist (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/boardchecklist.doc
     June 02, 2025 - Discuss major patient safety events/errors that have occurred in the most recent timeframe to show that

126. Measure Descriptions for Daily Early Mobility: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/modules/technical/daily-early-mobility-fac-guide.html
     February 01, 2017 - physical or occupational therapist, and finally, whether any adverse events associated with mobilization occurred … and, if so, what types of events occurred. … 29: Events Say: The next columns are designed to help track any adverse events that might have occurred … This field allows you to document up to three events if multiple events occurred. … Slide 30: Event Codes Say: If no adverse events occurred, use "0" (the code for "none") to indicate

127. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/measuredesc-dailyearlymobility-facguide.docx
     January 01, 2017 - physical or occupational therapist, and finally, whether any adverse events associated with mobilization occurred … and, if so, what types of events occurred. … Slide 28 Events SAY: The next columns are designed to help track any adverse events that might have occurred … This field allows you to document up to three events if multiple events occurred. … Slide 29 Event Codes SAY: If no adverse events occurred, use “0” (the code for “none”) to indicate

128. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/865598/psn-pdf
     April 17, 2024 - on an analysis of 520 transplant medication-related errors to summarize the types of mistakes that occurred

129. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/838632/psn-pdf
     October 19, 2022 - This systematic review including 13 studies found that nursing workarounds most often occurred due to

130. Final Progress Report: Mining complex clinical data for patient safety research (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/hripcsak-report.pdf
     January 01, 2024 - NLP successfully identified which of 45 NYPORTS events occurred in 57,452 discharge summaries, achieving … We also expected that it would often be unclear whether an error actually occurred. … If voluntary reporting occurred in the medical record, then this approach might reveal errors that would … The predictive value was best if the word occurred in the hospital course section of the discharge summary … detected conflicts in the medical record that might possibly signal that a medical adverse event has occurred

131. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866324/psn-pdf
     July 17, 2024 - This article summarizes a case where problems were not responded to, and harm occurred.

132. Module 1: An Overview of the CANDOR Process | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes1.html
     August 01, 2022 - understand what a CANDOR event is and what to do when they recognize that a CANDOR event is occurring or has occurred … Do: 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

133. USER GUIDE: Hand Hygiene Observational Audit Data Tracking Tool for Use in Skilled Nursing Facilities (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/hand-hygiene-audit-tool-userguide.pdf
     April 01, 2021 - location within your facility where the observational audit of the employee’s hand hygiene activity occurred … Next enter the date the audit occurred using the month/day/four-digit year format in Column E. … Select the time block that aligns with the time the audit occurred for the employee observed.

134. USER GUIDE: Personal Protective Equipment (PPE) COVID-19 Observational Audit Data Tracking Tool for Use in Skilled Nursing Facilities (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/ppe-covid19-audit-tracking-tool-userguide.pdf
     April 01, 2021 - enter the location within your facility where the observational audit of the employee’s PPE activity occurred … Next enter the date the audit occurred using the month/day/four-digit year format in Column E. … Select the time block that aligns with the time the audit occurred for the employee observed.

135. Mod5-Disclosure-Checklist (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/mod5-disclosure-checklist.pdf
     April 01, 2016 - after the CANDOR event is identified, advise the patient and/or family that an adverse event may have occurred … ■ Explain what is known about why the adverse event occurred; do not speculate.

136. Transformation to the Patient-Centered Medical Home in CareOregon Clinics | Agency for Healthcare Research and Quality
     www.ahrq.gov/ncepcr/research-transform-primary-care/transform/profile/meenan.html
     October 01, 2015 - Qualitative interviews with organizational leaders revealed that implementation occurred in two distinct … At 1 year post-implementation, 5.39 fewer inpatient admissions per month occurred in the PCR clinics

137. Final Progress Report: Creating Learning Cultures Around Mistakes for Residents (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/hoff-report.pdf
     January 01, 2024 - In addition, we looked for instances when errors or near misses occurred and how the interactions between … Regardless of setting, most errors occurred when the resident was alone. … Half (50%) of the 20 surgical resident mistakes and near misses occurred in isolation (i.e., no other … Surprisingly, in surgery’s case, 15 (75%) of the 20 mistakes and near misses occurred on the hospital … In the MICU case, although a higher percentage of mistakes occurred in isolation, 19 of the 21 mistakes

138. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/865346/psn-pdf
     March 27, 2024 - summarizes a presentation by a nurse charged criminally after a medication mistake, her memory of what occurred

139. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/851195/psn-pdf
     July 05, 2023 - This study of 7,452 pediatric patients with appendicitis found that delayed diagnosis occurred in 1.4%

140. Table 25. Utilization of education and case management (ECM) visits among adults who had at least one visit by type of visit. All project sites. Fiscal year 2010 | Agency for Healthcare Research and Quality
     www.ahrq.gov/practiceimprovement/delivery-initiative/ihs/chap6tab25.html
     December 01, 2017 - ECM visit 2.6 2.8 3.7 3.4 4.5 3.0 a Diabetes education visits are visits that occurred