Results

Total Results: over 10,000 records

Showing results for "occurred".

141. Blackbox: A Multidisciplinary Team-Based Framework for HIT Error Pattern Detection - Final Report (pdf file)
     digital.ahrq.gov/sites/default/files/docs/citation/r21hs024755-hettinger-final-report-2019.pdf
     January 01, 2019 - This allowed the team to standardize their approach in coding if an error occurred and what the evidence … , if a pause in workflow occurred and other elements. … After some investigation and changes within the EHR, the corrupted video files occurred infrequently … The team investigated evidence of diagnostic imaging studies that occurred on one side of the body … The remaining errors occurred during the modification of either order sets or the use of favorites

142. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866732/psn-pdf
     September 18, 2024 - Adverse events occurred across the medication process including prescribing, dispensing, and administration

143. 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

144. Final Progress Report: Factors Associated with Effective Implementation of a Surgical Safety Checklist (pdf file)
     www.ahrq.gov/sites/default/files/2024-04/singer-report.pdf
     January 01, 2024 - (1), occurred about 25% of the time (2), occurred about half of the time (3), occurred 75% of the time … (4), or always occurred during the case (5). … They also indicated that desired team-oriented behaviors occurred at least 75% of time (5 on 5-point … 82% of cases, respectively, they occurred at least 75% of the time. … Respectful behaviors occurred least frequently: in 67% of cases, they occurred at least 75% of the time

145. AHRQ's Safety Program for Nursing Homes: On-Time Falls Prevention Training (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallpxreports-ig.pdf
     June 02, 2025 - The new contributing risk factor elements represent changes that occurred in a resident’s clinical … It displays the number of falls that occurred and the risk factors associated with the falls. … For each of the months (1 or 3) included in the report, any fall that occurred before the report date … For each of the months (1 or 3) included in the report, any fall that occurred before the report date … ,  Shift during which the fall occurred,  Time at which the fall occurred,  The location of

146. 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

147. Appendix A. Recommendations for Ideal Consumer Reporting Systems (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/hotline/hotline-appendixa.pdf
     June 02, 2025 - The system should capture both objective information about what occurred and more-subjective information … Information collected from consumers should include where a patient safety event occurred; what contributed

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

149. 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

150. 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

151. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49425/psn-pdf
     November 01, 2003 - On face value, it is almost impossible to imagine how this could have occurred. … In addition to exploring why the error occurred at the level of individuals at the "sharp end," such … effectively, but involves interviewing staff involved to identify care management problems and why each occurred … Although physicians disclosed the adverse event, they often avoided stating that an error had occurred

152. 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

153. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49624/psn-pdf
     May 01, 2011 - This case highlights two important issues, namely how to talk with a patient or family when the error occurred … cases, this case has numerous dimensions of uncertainty, making it difficult to know whether an error occurred … Therefore, in cases where a potential error occurred under other providers, the critical first step is … In addition, if it was determined that an error occurred, a collaborative approach to disclosure, in … If they determined that a clear error occurred, providers should have found a way to disclose the error

154. 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

155. 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

156. 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

157. 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

158. Chipra204-Materials Iiia (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/CHIPRA204-Materials_IIIA.pdf
     January 01, 2014 - the medical record must include a note indicating a visit with a PCP, the date the well-child visit occurred … the medical record must include a note indicating a visit with a PCP, the date the well-child visit occurred … Measure of whether standardized development and behavioral screening using parent-completed tools occurred … Measure of whether standardized development and behavioral screening using parent-completed tools occurred

159. Chipra202-Materials Iiia (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/CHIPRA202-Materials_IIIA.pdf
     January 01, 2014 - the medical record must include a note indicating a visit with a PCP, the date the well-child visit occurred … the medical record must include a note indicating a visit with a PCP, the date the well-child visit occurred … Measure of whether standardized development and behavioral screening using parent-completed tools occurred … Measure of whether standardized development and behavioral screening using parent-completed tools occurred

160. Chipra205-Materials Iiia (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/CHIPRA205-Materials_IIIA.pdf
     January 01, 2014 - the medical record must include a note indicating a visit with a PCP, the date the well-child visit occurred … the medical record must include a note indicating a visit with a PCP, the date the well-child visit occurred … Measure of whether standardized development and behavioral screening using parent-completed tools occurred … Measure of whether standardized development and behavioral screening using parent-completed tools occurred