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Total Results: over 10,000 records

Showing results for "occurred".

261. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45427/psn-pdf
     October 19, 2016 - desire for more resources devoted to ensuring patient safety and more feedback after adverse events occurred

262. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39375/psn-pdf
     March 24, 2010 - discrepancies—differences between the medical record and patient self-report of their antihypertensive medications—occurred

263. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39954/psn-pdf
     November 26, 2014 - psnet.ahrq.gov/issue/incidence-adverse-drug-events-and-medication-errors-japan-jade-study Adverse drug events occurred

264. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40708/psn-pdf
     March 02, 2012 - For specified events, the influence of perceived barriers was dependent on whether an error actually occurred

265. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49420/psn-pdf
     October 01, 2003 - Fortunately, no long-term sequelae occurred as a consequence of the errors in care suffered by this … Four distinct errors occurred in this case. … The errors in execution made by the original provider likely would not have occurred in less hectic … laboratory could have been more proactive about clarifying information, but had errors one and two not occurred

266. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/854818/psn-pdf
     October 25, 2023 - from one medical center in the Netherlands and found that diagnostic testing errors most commonly occurred

267. Facilitator Guide: Learning From Defects Through Sensemaking (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects_facnotes.docx
     December 01, 2017 - So, first look at the system and analyze why the mistake occurred. … What actions occurred? What were the team members thinking and feeling? … SAY: These are the types of questions to ask to understand how a defect occurred. … Try to find out exactly how things occurred in real time. Slide 13 What Happened? … No timeouts or debriefings occurred. NOTE: Spend 10 to 15 minutes discussing the case.

268. Accessible Facilitator Guide: Learn From Defects for Sustainability (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_learn_from_defects_facnotes.docx
     December 01, 2017 - ASK: What if the same situation occurred on a different shift? … SAY: When a defect has already occurred, ask your frontline staff. … ASK: How do all these pieces lead to this error or the event that occurred? … If you can, simulate the defect, particularly for a defect that has occurred. … SAY: If a contributing factor is a major reason why the defect occurred, place that factor in the top

269. Sustainability: Learning From Defects: Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/surgery/modules/sustainability/learn-from-defects-fac-notes.html
     December 01, 2017 - Ask: What if the same situation occurred on a different shift? … Say: When a defect has already occurred, ask your frontline staff. … Ask: How do all these pieces lead to this error or the event that occurred? … If you can, simulate the defect, particularly for a defect that has occurred. … Say: If a contributing factor is a major reason why the defect occurred, place that factor in the top

270. An Overview of the CANDOR Process
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4/module4-event-reporting-investigation-analysis.pptx
     September 10, 2015 - 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

271. Facts and Figures Exhibit 5.3
     hcup-us.ahrq.gov/reports/factsandfigures/2007/exhibit5_3.jsp
     January 01, 2007 - For stays with Medicare as the primary payer, in-hospital deaths occurred in 4 percent of stays. … Three percent of uninsured discharges occurred against medical advice, compared to less than 1 percent

272. Appendix A. Recommendations for Ideal Consumer Reporting Systems | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/hotline/appa.html
     May 01, 2016 - 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

273. Tool: Premortem (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/premortem-tool.docx
     January 01, 2017 - · “Spend the next 10 minutes writing down all the reasons you believe this failure occurred. … Please spend the next 10 minutes writing down all the reasons you believe this failure occurred.

274. Premortem Tool | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/modules/cusp/premortem-tool.html
     January 01, 2017 - "Spend the next 10 minutes writing down all the reasons you believe this failure occurred. … Please spend the next 10 minutes writing down all the reasons you believe this failure occurred.

275. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49512/psn-pdf
     May 01, 2006 - The first error (or series of errors) occurred 2 weeks prior to admission when the staff in the ED who … The next group of errors occurred when the patient was admitted. … The final set of errors occurred prior to the patient receiving spinal anesthesia. … such as cardiac arrest and neurological complications.(9) The institution at which this adverse event occurred … process of identifying and labeling radiographs should be reviewed to discover exactly how the errors occurred

276. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39675/psn-pdf
     January 19, 2011 - This review of rapid response system calls to an inpatient hemodialysis unit found that many events occurred

277. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42071/psn-pdf
     February 27, 2013 - measure the impact of such misidentification, the findings raise concern that diagnostic errors may have occurred

278. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38869/psn-pdf
     August 19, 2009 - Approximately 1 in 60 prescriptions for parenteral nutrition resulted in a medication error, most of which occurred

279. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37132/psn-pdf
     June 14, 2011 - Most errors occurred at the transcription stage, and a substantial proportion were attributed to poor

280. Table 26. Utilization of education and case management service by type of visit among adults with diabetes who had at least one visit. Fiscal year 2010 | Agency for Healthcare Research and Quality
     www.ahrq.gov/practiceimprovement/delivery-initiative/ihs/chap6tab26.html
     December 01, 2017 - 33.1% 36.7% 3.8% 9.3% 100.0% 38.9% a Diabetes education visits are visits that occurred