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Showing results for "occurred".

21. Critical Incident Technique | Digital Healthcare Research
    digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/critical-incident-technique
    January 01, 2023 - The goal is also to determine why these actions occurred and why the decisions were made. … The goal is to provide the analyst with an accurate view of what occurred, including the time and duration

22. 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…

23. 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.

24. 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.

25. 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

26. 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.

27. 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

28. 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

29. 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

30. 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

31. 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.

32. 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

33. Final Progress Report: Evaluation of Risk by Active Surveillance in the Emergency Department (ERASED) (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/hall1-report.pdf
    January 01, 2024 - 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

34. Medication errors in the care transition of trauma patients | PSNet
    psnet.ahrq.gov/issue/medication-errors-care-transition-trauma-patients
    September 02, 2020 - This observational, descriptive, prospective study comprises an analysis of the medication errors that occurred … Results indicate that most medication errors occurred in the trauma unit and 64.2% of these types of

35. Enteral nutrition: an underappreciated source of patient safety events. | PSNet
    psnet.ahrq.gov/issue/enteral-nutrition-underappreciated-source-patient-safety-events
    February 01, 2023 - reported events were classified as "care management events," eg, incorrect rate or dosage; 31% of errors occurred … during administration ; and 28% occurred during monitoring.

36. The patients' perspective: hematological cancer patients' experiences of adverse events as part of care. | PSNet
    psnet.ahrq.gov/issue/patients-perspective-hematological-cancer-patients-experiences-adverse-events-part-care
    December 01, 2019 - 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

37. Critical incidents involving the medical emergency team: a 5-year retrospective assessment for healthcare improvement. | PSNet
    psnet.ahrq.gov/issue/critical-incidents-involving-medical-emergency-team-5-year-retrospective-assessment
    November 11, 2020 - 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.

38. Identifying health information technology usability issues contributing to medication errors across medication process stages. | PSNet
    psnet.ahrq.gov/issue/identifying-health-information-technology-usability-issues-contributing-medication-errors
    November 03, 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.

39. 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

40. 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