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Showing results for "occurred".

21. Final Progress Report: Weekend Effects and the July Phenomenon in Patient Safety (pdf file)
    www.ahrq.gov/sites/default/files/2024-09/weissman-report.pdf
    January 01, 2024 - Complications related to anesthesia occurred less frequently on weekends (OR 0.86). … Then, using state discharge data, we investigated whether PSIs occurred more frequently on weekends. … hospitals and, among teaching hospitals, whether PSIs occurred more frequently in July. … the complication occurred on a weekend or a weekday. … Thus, the PSIs will be assigned to the month in which the admission occurred.

22. Efforts To Improve Patient Safety Result in 1.3 Million Fewer Patient Harms | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/pfp/interimhacrate2013.html
    November 01, 2015 - experienced by hospital patients in 2011, 2012, and 2013 relative to the number of HACs that would have occurred … 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 … 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 15

23. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/866692/psn-pdf
    September 11, 2024 - This study used 8 years of medication records to identify when in the medication process the error occurred … Nearly one-third of errors were wrong dose and occurred in the prescribing stage.

24. Quantitative and Qualitative Analysis of Medication Errors: The New York Experience (pdf file)
    www.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.

25. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/73465/psn-pdf
    July 07, 2021 - event reports to identify the type of medication error, the stage in the process in which the error occurred … Errors in dosing were the most frequent type, and occurred during ordering or reviewing.

26. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/73181/psn-pdf
    April 28, 2021 - This retrospective study analyzed critical incidents that occurred during MET responses over a five-year … They mainly occurred due to lack of compliance with protocols and lack of available supplies.

27. Do Transient Working Conditions Trigger Medical Errors? (pdf file)
    www.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.

28. Adverse drug events in hospitalized cardiac patients. | PSNet
    psnet.ahrq.gov/issue/adverse-drug-events-hospitalized-cardiac-patients
    July 26, 2023 - Preventable ADEs most frequently occurred during medication administration , and cardiovascular agents … Interestingly, the most preventable ADEs occurred between 7:00 AM and 9:00 AM, during handoffs between

29. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/73603/psn-pdf
    August 18, 2021 - In this study of oncology patients, more than one quarter perceived an adverse event had occurred. … While most were informed soon after the event occurred and given an explanation, fewer than half were

30. When errors occur. | PSNet
    psnet.ahrq.gov/issue/when-errors-occur
    March 12, 2011 - Newspaper/Magazine Article When errors occur. Citation Text: Wetzel TG. When errors occur, 'I'm sorry' is a big step, but just the first. Hospitals & health networks. 2010;84(10):41-2, 44, 2. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML En…

31. Tenfold medication errors: 5 years' experience at a university-affiliated pediatric hospital. | PSNet
    psnet.ahrq.gov/issue/tenfold-medication-errors-5-years-experience-university-affiliated-pediatric-hospital
    August 07, 2024 - resulted in patient harm in the outpatient setting , and this study found that more than 250 such errors occurred … Although pharmacists intercepted nearly half the errors, more than one-third occurred at the time of

32. Chapter 3. Structure of Learning Network | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/findings/final-reports/diabetesnetwork/diabnet3.html
    October 01, 2014 - Learning Sessions occurred in July and September 2006 and January 2007. … To maximize interaction among participating clinic teams, two telephone conference calls occurred to

33. Patient falls while under supervision: trends from incident reporting. | PSNet
    psnet.ahrq.gov/issue/patient-falls-while-under-supervision-trends-incident-reporting
    January 11, 2023 - Findings indicate that nearly one in five falls occurred while the patient was under enhanced supervision … and most commonly occurred in the patient’s bathroom or bedside.

34. Aspiration Pneumonitis/Pneumonia (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/best-practices/asp-pneumonitis-one-page.pdf
    November 01, 2019 - regimens for community-acquired pneumonia (CAP) (e.g., ampicillin- sulbactam, ceftriaxone) if the event occurred … regimens for hospital-acquired pneumonia (HAP) (e.g., cefepime, piperacillin- tazobactam) if the event occurred

35. Learning from Patient Narratives Through Innovative Feedback Reporting Methods Webcast - Impact of the Intervention on Staff Experience (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/learning_pt_narratives_053123-nembhard.pdf
    June 02, 2025 - Problems that occurred between patients and clinicians or staff 7. Exceptional people 8. … exceptional people exceptional ways to do things problems with the practice’s day-to-day … problems that occurred … ) 0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 Exceptional ways to do things Exceptional people Problems that occurred

36. Conducting a Morning Briefing | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/cusp/toolkit/morning-briefing.html
    December 01, 2012 - This tool provides a structured approach to help physicians and nurses identify the problems that occurred … If an adverse event occurred, you should also use the Learn From Defects Form.

37. Prescription Screening Form | Digital Healthcare Research
    digital.ahrq.gov/health-it-tools-and-resources/ahrq-funded-project-resources-archives/prescription-screening-form
    January 01, 2023 - Description This is a form to classify prescriptions based on type and what adverse events occurred

38. Hospital Evacuation Decision Guide | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/shuttered/hospevac4.html
    July 01, 2018 - Post-Event Evacuation Decision Guide Post-event evacuations have occurred either following Advanced … Sequence in a Post-Event Evacuation If the decision is made to begin an evacuation after the event has occurred … filled with water from the nearby Haw Creek and power was lost. 53 The full evacuation of 157 patients occurred

39. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/37309/psn-pdf
    January 05, 2012 - Preventable ADEs most frequently occurred during medication administration, and cardiovascular agents … Interestingly, the most preventable ADEs occurred between 7:00 AM and 9:00 AM, during handoffs between

40. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/33592/psn-pdf
    December 15, 2024 - 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 … could have been less harmful if care had been different; Adverse events due to negligence: those that occurred