Results

Total Results: over 10,000 records

Showing results for "occurred".

161. Multimodal system designed to reduce errors in recording and administration of drugs in anaesthesia: prospective randomised clinical evaluation. | PSNet
     psnet.ahrq.gov/issue/multimodal-system-designed-reduce-errors-recording-and-administration-drugs-anaesthesia
     September 26, 2012 - Although fewer overall errors occurred with the new system, the reduction in administration errors occurred

162. Final Progress Report: Brief, Risky, High-Benefit Procedures: Best Practice Model (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/mackenzie-report.pdf
     January 01, 2024 - No operator injuries occurred with a redesigned instrument tray. … Complications of CTI in one study of 426 consecutive patients occurred in 21%. … Undrained pneumothorax, hemothorax, or effusion despite CTI occurred in 35 patients. … In one of these patients, the air re-accumulation occurred after hospital discharge. … In one patient, this occurred 5 days after hospital discharge (Fig. 5).

163. AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention Training | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/reportguide.html
     November 01, 2017 - 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 … 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 the fall

164. Mitchell E et al. 2001 "A descriptive feast but an evaluative famine: systematic review of published articles on primary care computing during 1980-97." | Digital Healthcare Research
     digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/mitchell-e-et-al-2001
     January 01, 2001 - Again the largest increase occurred with an electronic protocol, and consultation length increased by … The greatest increases occurred when physicians were prompted as part of the consultation." … The greatest improvement in disease management "occurred when physicians used an electronic protocol,

165. A Comparison of All-Cause 7-Day and 30-Day Readmissions, 2014 (pdf file)
     hcup-us.ahrq.gov/reports/statbriefs/sb230-7-Day-Versus-30-Day-Readmissions.pdf
     December 01, 2016 - For diagnoses with the highest 7-day readmission rates, the percentage of 30-day readmissions that occurred … More than one-third of these readmissions occurred within 7 days, reflecting a 7-day readmission rate … Overall, 36.1 percent of all 30-day readmissions occurred within 7 days. … Across payers, the percentage of 30-day readmissions that occurred within 1 week of initial discharge … In comparison, 31–32 percent of 30-day readmissions for CHF occurred within 7 days across payers.

166. Adverse Events, Near Misses, and Errors | PSNet
     psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors
     March 30, 2022 - independently reviewed by two clinically experienced reviewers in order to determine whether an adverse event occurred … When an adverse event occurred, reviewers also may disagree about whether the event was preventable. … Important subcategories of adverse events include: Preventable adverse events : those that occurred due … could have been less harmful if care had been different; Adverse events due to negligence : those that occurred

167. The Nature, Characteristics and Patterns of Perinatal Critical Events Teams (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Riley_58.pdf
     April 02, 2008 - to execute a specific task, whereas “team reformation” occurred when team membership changed in a … Each behavioral marker was scored using the following scale: • “0” Behavior occurred at or below … • “2” Behavior occurred more than 90 percent of the times when prompted by the event set. … emergency measures; and planning for an emergency intervention occurred. … Leadership transfer occurred continuously throughout an obstetrics emergency.

168. A Fresh Look at the Data Shows Patient Safety Improving Overall, With Improvement Still Needed in Many Areas | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/blog/ahrqviews/fresh-look-at-ptsafety-data.html
     October 01, 2018 - These gains and others show where progress has occurred.  … a reminder that in many areas where quality improvement efforts are gaining ground, success has not occurred

169. AHRQ-Funded Program Helps Long-Term Care Provider Reduce Falls | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/cdom0604.html
     October 01, 2014 - collection had shown BHRS administrators that half of the residents had only one fall and most falls occurred … In addition, most falls occurred within the first few weeks of admission.

170. Chapter 9. Potential Future Uses of the Data Infrastructure | Agency for Healthcare Research and Quality
     www.ahrq.gov/practiceimprovement/delivery-initiative/ihs/chapter9.html
     December 01, 2017 - following the visit may be used to assess if laboratory testing, medication changes, and ECM service use occurred … If such service use occurred following the visit, the office visit may be classified as a clinical opportunity

171. An Analysis of Nurses' Cognitive Work: A New Perspective for Understanding Medical Errors (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Potter.pdf
     January 01, 2003 - The total number of links was summarized and grouped, then the number of activities that occurred for … Calculations were made to show the cognitive load at the time each interruption occurred and at the … Omissions for RN #3 occurred with a cognitive stacking load of 16, 18, 17, and 16 respectively. … Omissions occurred at various times with respect to a nurse’s cognitive stacking measure. … For example, an omission occurred with a nurse’s cognitive stacking as low as 5 and as high as 20.

172. Preparing for Ambulatory Computerized Prescriber Order Entry by Evaluating Preimplementation Medication Errors (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Devine.pdf
     July 01, 2003 - , but the medication did not reach the patient C An error occurred that reached the patient but did … but no patient harm Error, harm E An error occurred that resulted in the need for treatment or … hospitalization and caused temporary patient harm G An error occurred that resulted in permanent … patient harm H An error occurred that resulted in a near-death event (e.g., anaphylaxis, cardiac … A 5-month time frame was identified; in an effort to minimize bias, one that occurred immediately prior

173. Quantitative and Qualitative Analysis of Medication Errors: The New York Experience (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Duthie.pdf
     January 01, 2004 - -G- An error occurred that may have contributed to or resulted in permanent patient harm. 109 A … medication error occurred that resulted in a near-death event (e.g., anaphylaxis, cardiac arrest). … -H- An error occurred that required an intervention necessary to sustain life. 110 A medication … error occurred that resulted in a patient death. … -I- An error occurred that may have contributed to or resulted in the patient’s death.

174. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits - Functional Specifications (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallspxspecs.pdf
     February 01, 2018 - type occurred daily. … type occurred daily. … type occurred daily. … type occurred daily. … type occurred daily.

175. 5. How do you measure fall rates and fall prevention practices? | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/measure-fall-rates.html
     January 01, 2013 - With each fall, you will need to define the level of injury that occurred, if any. … The patient in whom the fall occurred. The date the fall occurred. … But for calculation of a fall rate, you need the date the fall occurred and the responsible unit (if … Rates are calculated as follows: First, count the number of falls that occurred during the month … Try to understand why the fall occurred and how such an incident might be prevented in the future.

176. Improving the Safety of Heparin Administration by Implementing a Human Factors Process Analysis (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Harder.pdf
     May 19, 2003 - Brennan et al.1 reported that adverse events occurred in 3.7 percent of the selected cases (95% confidence … Thomas et al.2 reported that in this sample, adverse events occurred at a rate of 2.9 percent (with … Death occurred in 6.6 percent (SD of 1.2 percent) of the adverse events. … in 2003.4 Not surprisingly, the results of the studies of adverse events that occurred in Utah and … This education occurred on the patient care units 24 hours a day for the 5-day process.

177. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49395/psn-pdf
     April 01, 2003 - references 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 … (Figure 1, Figure 2) The error in this case occurred independent of prescription legibility. … confusion between ‘dose’ and ‘day,’ due to ambiguous use of the abbreviation “d” in “mg/kg/d,” could have occurred … ensures that orders are complete and in a standard format, eliminating ambiguous dosing orders as occurred

178. Module 4: Event Reporting, Event Investigation and Analysis | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes4.html
     August 01, 2022 - information, other than event reports, that might provide information indicating that a CANDOR event has occurred … create a cohesive environment for informing the organization as to whether a CANDOR event may have occurred … implement the best practice of creating a hotline for staff to call when they feel a CANDOR event has occurred … Risk Management can also provide ongoing support to managers on the unit(s) where the event occurred. … Also, the location where the event occurred is generally no longer intact, so information that could

179. Module 5: Response and Disclosure | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/notes.html
     August 01, 2022 - The patient and/or family have a reasonable expectation to be informed when a harm event has occurred … of this initial conversation is to advise the patient and/or family that an adverse event may have occurred … During disclosure, patients and families generally want a clear, explicit statement that an event has occurred … what happened in a way that is easy to understand, explain what is known about why the adverse event occurred … If the event was preventable and occurred due to error, the communicator should: Consider using

180. Do Transient Working Conditions Trigger Medical Errors? (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Grayson.pdf
     January 01, 2003 - , as compared with shifts when no errors occurred. … Subjects were first asked the dates and times of the shift on which the error occurred and the prior … , and the last shift worked by the subject prior to the shift on which the error occurred. … assumption that no error occurred on the prior shift worked. … Subjects were also asked if a significant unplanned event or break in policy occurred.