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Showing results for "occurred".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867020/psn-pdf
    October 23, 2024 - discusses an effort in the United Kingdom to learn from preventable deaths reported to coroners that occurred

  2. Learning From Defects Through Sensemaking: Facilitator Notes | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-fac-notes.html
    December 01, 2017 - So, first look at the system and analyze why the mistake occurred. … What actions occurred? What were the team members thinking and feeling? … Say: These are the types of questions to ask to understand how a defect occurred. … Try to find out exactly how things occurred in real time. Slide 14: What Happened? … No timeouts or debriefings occurred. Note: Spend 10 to 15 minutes discussing the case.

  3. 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

  4. 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.

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72522/psn-pdf
    December 02, 2020 - Conducted at a single emergency department (ED) in Italy, this study found that nurse-led triage errors occurred

  6. Appendix 1-B. Pre/Post-Test Questions and Answers for Module 1 | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/gdmodap1b.html
    October 01, 2014 - You do nothing, as this is the first time it has occurred. … You do nothing, as this is the first time it has occurred.

  7. Transformation to the Patient-Centered Medical Home in CareOregon Clinics (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/tpc/tpc-profile-meenan.pdf
    April 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

  8. Procedure Manual Appendix II: USPSTF Conflict of Interest Disclosure Form | United States Preventive Services Taskforce

    www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/procedure-manual/procedure-manual-appendix-ii-uspstf-conflict-interest-disclosure-form
    July 01, 2017 - Type of Financial Interest Amount ($) Description Date Potential COI Occurred (mm/yy) … Member Relationship Type of Financial Interest Amount ($) Description Date Potential COI Occurred … Organization Role Type of Participation (Paid/Unpaid) Description Date Potential COI Occurred

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73535/psn-pdf
    July 28, 2021 - inpatients at one New York hospital between 2016 and 2018 and found that wrong- patient order errors occurred

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866693/psn-pdf
    September 11, 2024 - This analysis of 91 incident reports from care homes in England examined patient safety events that occurred

  11. Board Checklist | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/board-checklist.html
    July 01, 2023 - Discuss major patient safety events/errors that have occurred in the most recent timeframe to show that

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865702/psn-pdf
    May 01, 2024 - Most errors occurred post- operatively (including after discharge) and in colorectal and hepatobiliary

  13. Chapter 2. Fall Response | Agency for Healthcare Research and Quality

    www.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

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73176/psn-pdf
    April 28, 2021 - The most common diagnostic errors occurred in cardiovascular, infectious, congenital, and neurologic

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60895/psn-pdf
    September 09, 2020 - radiology fellows working off-hours over a four- year period and found that interpretation errors occurred

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851653/psn-pdf
    July 26, 2023 - this study, nurses at one Australian hospital provided a reflection as to why they believed an MAE occurred

  17. Hospital Stays Related to Child Maltreatment, 2005 (pdf file)

    hcup-us.ahrq.gov/reports/statbriefs/sb49.pdf
    April 01, 2008 - ospital deaths related to atment occurred in infants ildren younger than five ld. … 79.4 t of maltreatment-related ic hospitalizations. 36 percent of lizations related to atment occurred … Only 13.7 t occurred among children n the wealthiest nities. … In 2005, four out of five maltreatment-related hospitalizations (79.4 percent) occurred among children … Only 5.0 percent of maltreatment-related stays occurred among teenagers aged 15 to 17 years old, but

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34936/psn-pdf
    March 12, 2009 - https://psnet.ahrq.gov/issue/another-fatal-failure-kingdrew This article reports on a death that occurred

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33778/psn-pdf
    March 01, 2015 - Two clinician reviewers judged misdiagnosis to have occurred in 5% of these children presenting with … Major discrepancies occurred in 41 shifts over a 13-month period. … Significantly more diagnostic errors occurred with salient distracting features, especially for complex … examination showed that, for cases involving diagnosis, changing an answer from incorrect to correct occurred

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838134/psn-pdf
    September 21, 2022 - This study analyzed allergic adverse drug events that occurred because of overridden drug allergy alerts
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