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Showing results for "occurred".

141. How useful are voluntary medication error reports? The case of warfarin-related medication errors. | PSNet
     psnet.ahrq.gov/issue/how-useful-are-voluntary-medication-error-reports-case-warfarin-related-medication-errors
     May 27, 2011 - Investigators discovered that inpatient warfarin-related errors occurred most frequently during transcription … /documentation and administration, while outpatient errors occurred most frequently during prescribing

142. Final Progress Report: Evaluation of Risk by Active Surveillance in the Emergency Department (ERASED) (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/17111-Hall-report.pdf
     September 01, 2007 - events were categorized into two taxonomies: (1) the segment of emergency care in which the event occurred … Patient visits were eligible for inclusion if (1) the visit occurred in the adult emergency department … An additional category, transitions, was added to account for periods when an event occurred during … The nonideal care events were categorized into the segment of care in which they occurred (Figure 1) … Significant time was spent distinguishing the true process from workarounds, which occurred between

143. Event Investigation and Analysis Guide: Appendix C | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/capacity/candor/modules/guide4/apc.html
     February 01, 2017 - This format helps to utilize the information found in the investigation to understand why the event occurred

144. HAC National Scorecard 2014-16 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac-scorecard-2014-16.pdf
     January 01, 2014 - HAC National Scorecard 2014-16 Between 2014-2016, 350,000 fewer hospital-acquired conditions (HACs) occurred

145. What Happens After a Patient Safety Event? Medical Expenditures and Outcomes in Medicare (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Encinosa.pdf
     January 01, 2003 - period the IOM report was released), we examine potentially preventable adverse medical events that occurred … The unit of observation was any major surgery admission (identified as the “index” surgery) that occurred … The surgeries occurred at 1,725 hospitals nationwide. … potentially preventable adverse medical events only cases in which the evidence that such an event occurred … Thus, there may have been many more preventable safety events (as well as close calls) that occurred

146. S89 (pdf file)
     effectivehealthcare.ahrq.gov/sites/default/files/s89.pdf
     October 01, 2007 - in the vaccinated group, whereas 1 had occurred in the control group (Table 1). … At week 12, 2 cases occurred in the vaccinated group compared with no cases in the control group, for … A third case occurred in the vaccinated group during week 14, with an increase in LLR to 2.08. … Hypothetically, the LLR would have been different if the fourth case of facial paralysis had occurred … If 3 cases had occurred during week 12, the LLR would have been 7.86, exceeding the critical value at

147. S89 (pdf file)
     effectivehealthcare-admin.ahrq.gov/sites/default/files/s89.pdf
     October 01, 2007 - in the vaccinated group, whereas 1 had occurred in the control group (Table 1). … At week 12, 2 cases occurred in the vaccinated group compared with no cases in the control group, for … A third case occurred in the vaccinated group during week 14, with an increase in LLR to 2.08. … Hypothetically, the LLR would have been different if the fourth case of facial paralysis had occurred … If 3 cases had occurred during week 12, the LLR would have been 7.86, exceeding the critical value at

148. Telehealth and Emergency Medicine: A Consensus Conference to Map the Intersection of Emergency Medicine and Telehealth - Final Report (pdf file)
     digital.ahrq.gov/sites/default/files/docs/citation/r13hs027528-clark-final-report-2021.pdf
     January 01, 2021 - Co-chairs reviewed the summaries and ensured no overlap occurred. … The sixth step occurred on Day 1 of the virtual conference. … The seventh step occurred on Day 2 of the conference. … The eighth step occurred after the conference. … Round 2 of the voting occurred after the first conference day, and round 3 occurred live in the second

149. Final Progress Report: Pediatric Medication Safety: Analyses from the MEDMARX Medication Error Reporting System (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/bundy-report.pdf
     January 01, 2024 - Categories E through H errors not only occurred and reached the patient but also caused harm. … In one study of nationally representative US data, extra vaccination occurred in 21% of young children … Harmful errors occurred with all cardiovascular drug classes. … However, because over half the errors occurred at the administering stage of medication processing, … Not surprisingly, a large majority of reported pediatric antidepressant medication errors occurred

150. From physician intent to the pharmacy label: prevalence and description of discrepancies from a cross-sectional evaluation of electronic prescriptions. | PSNet
     psnet.ahrq.gov/issue/physician-intent-pharmacy-label-prevalence-and-description-discrepancies-cross-sectional
     July 22, 2020 - The investigators found that errors occurred at each stage of the process, with a small but significant … These errors often occurred when providers entered free-text instructions into the e-prescribing system

151. Final Progress Report: Medication Error Reduction, Technologies and Human Factors (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/carayon-report.pdf
     January 01, 2024 - The pump observations occurred 1 month before Smart IV pump implementation and 5 months 4 after … Forty-six hours of meeting time occurred over 4.5 months, representing 600 person-hours of time. … The second round of usability testing occurred with what was ultimately the final pump. … There were nine different units and the emergency department on which the observations occurred. … Staff were unaware and surprised that an UNDER- infusion most likely occurred in these cases.

152. 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013 | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/hai/pfp/hacrate2013.html
     January 01, 2018 - hospital patients over the 3 years (2011, 2012, 2013) relative to the number of HACs that would have occurred … precise causes of the decline in patient harm are not fully understood, the increase in safety has occurred … Costs included the initial hospital stay and costs of other inpatient sites of care that occurred within … in 2013 than would have occurred if the rate of HACs had remained steady at the 2010 level (Exhibit … The majority of deaths averted occurred as a result of reductions in the rates of pressure ulcers 14

153. 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013 | Agency for Healthcare Research and Quality
     www.cahps.ahrq.gov/hai/pfp/hacrate2013.html
     January 01, 2018 - hospital patients over the 3 years (2011, 2012, 2013) relative to the number of HACs that would have occurred … precise causes of the decline in patient harm are not fully understood, the increase in safety has occurred … Costs included the initial hospital stay and costs of other inpatient sites of care that occurred within … in 2013 than would have occurred if the rate of HACs had remained steady at the 2010 level (Exhibit … The majority of deaths averted occurred as a result of reductions in the rates of pressure ulcers 14

154. 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013 | Agency for Healthcare Research and Quality
     www.healthcare411.ahrq.gov/hai/pfp/hacrate2013.html
     January 01, 2018 - hospital patients over the 3 years (2011, 2012, 2013) relative to the number of HACs that would have occurred … precise causes of the decline in patient harm are not fully understood, the increase in safety has occurred … Costs included the initial hospital stay and costs of other inpatient sites of care that occurred within … in 2013 than would have occurred if the rate of HACs had remained steady at the 2010 level (Exhibit … The majority of deaths averted occurred as a result of reductions in the rates of pressure ulcers 14

155. 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013 | Agency for Healthcare Research and Quality
     www.cpsi.ahrq.gov/hai/pfp/hacrate2013.html
     January 01, 2018 - hospital patients over the 3 years (2011, 2012, 2013) relative to the number of HACs that would have occurred … precise causes of the decline in patient harm are not fully understood, the increase in safety has occurred … Costs included the initial hospital stay and costs of other inpatient sites of care that occurred within … in 2013 than would have occurred if the rate of HACs had remained steady at the 2010 level (Exhibit … The majority of deaths averted occurred as a result of reductions in the rates of pressure ulcers 14

156. 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013 | Agency for Healthcare Research and Quality
     www.monahrq.ahrq.gov/hai/pfp/hacrate2013.html
     January 01, 2018 - hospital patients over the 3 years (2011, 2012, 2013) relative to the number of HACs that would have occurred … precise causes of the decline in patient harm are not fully understood, the increase in safety has occurred … Costs included the initial hospital stay and costs of other inpatient sites of care that occurred within … in 2013 than would have occurred if the rate of HACs had remained steady at the 2010 level (Exhibit … The majority of deaths averted occurred as a result of reductions in the rates of pressure ulcers 14

157. 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013 | Agency for Healthcare Research and Quality
     www.innovations.ahrq.gov/hai/pfp/hacrate2013.html
     January 01, 2018 - hospital patients over the 3 years (2011, 2012, 2013) relative to the number of HACs that would have occurred … precise causes of the decline in patient harm are not fully understood, the increase in safety has occurred … Costs included the initial hospital stay and costs of other inpatient sites of care that occurred within … in 2013 than would have occurred if the rate of HACs had remained steady at the 2010 level (Exhibit … The majority of deaths averted occurred as a result of reductions in the rates of pressure ulcers 14

158. 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013 | Agency for Healthcare Research and Quality
     www.qualitymeasures.ahrq.gov/hai/pfp/hacrate2013.html
     January 01, 2018 - hospital patients over the 3 years (2011, 2012, 2013) relative to the number of HACs that would have occurred … precise causes of the decline in patient harm are not fully understood, the increase in safety has occurred … Costs included the initial hospital stay and costs of other inpatient sites of care that occurred within … in 2013 than would have occurred if the rate of HACs had remained steady at the 2010 level (Exhibit … The majority of deaths averted occurred as a result of reductions in the rates of pressure ulcers 14

159. 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013 | Agency for Healthcare Research and Quality
     www.talkingquality.ahrq.gov/hai/pfp/hacrate2013.html
     January 01, 2018 - hospital patients over the 3 years (2011, 2012, 2013) relative to the number of HACs that would have occurred … precise causes of the decline in patient harm are not fully understood, the increase in safety has occurred … Costs included the initial hospital stay and costs of other inpatient sites of care that occurred within … in 2013 than would have occurred if the rate of HACs had remained steady at the 2010 level (Exhibit … The majority of deaths averted occurred as a result of reductions in the rates of pressure ulcers 14

160. AHRQ Mastectomy SB Infographic v15 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/double-mastectomy.pdf
     February 01, 2016 - The rise in mastectomies occurred despite breast cancer rates remaining constant. 2005 2013 Sharp