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Showing results for "occurred".

  1. Making Just Culture a Reality: One Organization's Approach | PSNet

    psnet.ahrq.gov/perspective/making-just-culture-reality-one-organizations-approach
    October 01, 2007 - In 2001, an accident occurred in our interventional MRI room when a piece of equipment flew across the … Even before the event occurred, they contributed through the quality of the choices that they made.

  2. Two Wrongs Don't Make a Right (Kidney) | PSNet

    psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney
    April 01, 2010 - The second error occurred during the patient transfer, when only the records, but not the imaging, accompanied … The third error occurred as the patient was posted for the surgical suite without preoperative imaging … These three errors occurred before the patient was rolled into the surgical suite. … The fourth error occurred once in the operating room—implementation of the Universal Protocol could have

  3. Statistical Brief #4

    hcup-us.ahrq.gov/reports/statbriefs/sb4.jsp
    May 01, 2006 - In 2003, nearly three out of four hospital stays for alcohol abuse occurred in men, making it one of … almost half of all hospitalizations for alcohol abuse, while another 42 percent of these hospital stays occurred … Less than 8 percent of alcohol-related stays occurred among patients 65 and older. … More than 90 percent of hospitalizations for alcohol abuse occurred among adult patients under 64, with

  4. Methodology Report #19: Overview of Methodology for Imputing Missing Expenditure Data in the Medical Expenditure Panel Survey

    meps.ahrq.gov/data_files/publications/mr19/mr19.shtml
    March 01, 2007 - care are not considered a proxy for payments, primarily due to two important trends that have occurred

  5. Health Care–Acquired Urinary Tract Infection: The Problem and Solutions | PSNet

    psnet.ahrq.gov/perspective/health-care-acquired-urinary-tract-infection-problem-and-solutions
    November 01, 2008 - Physicians may, in fact, be unaware that a patient under their care has an indwelling catheter—this occurred

  6. A Nonpunitive, Computerized System for Improved Reporting of Medical Occurrences (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Arroyo.pdf
    June 11, 2003 - It called for a nonpunitive approach when dealing with staff and handling errors that occurred.

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49786/psn-pdf
    March 01, 2017 - Had this catastrophic outcome not occurred, the patient would have likely undergone one or more unnecessary

  8. Making Effective Behavior Changes Around Antibiotic Prescribing (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/improve/behavior-change-facilitator-guide.pdf
    November 01, 2019 - No additional interventions had occurred in the intervening years.

  9. Final Progress Report: Preventing/Managing C. Diff for Nursing Home Residents, Admissions, and Discharges (pdf file)

    www.ahrq.gov/sites/default/files/2024-01/phillips-report.pdf
    January 01, 2024 - These Minimum Data Set (MDS) assessments occurred between October 1, 2010, and December 31, 2011.

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49675/psn-pdf
    February 01, 2013 - Then the patient did not return for treatment for another 2 weeks, by which time significant harm had occurred

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49666/psn-pdf
    October 01, 2012 - Among athletes, CA-MRSA outbreaks have occurred at the high school, college, and professional level

  12. Weighing In on Surgical Safety | PSNet

    psnet.ahrq.gov/web-mm/weighing-surgical-safety
    August 04, 2021 - If the trachea is not successfully intubated and mask ventilation becomes "impossible" (as occurred in

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49546/psn-pdf
    October 17, 2007 - Professionalism Among Trainees Identifying and tracking critical incidents of unprofessional behavior, as occurred

  14. Verification Screen That Includes Prominent Patient Photograph Significantly Reduces Errors Caused by Orders Placed in Wrong Chart | PSNet

    psnet.ahrq.gov/innovation/verification-screen-includes-prominent-patient-photograph-significantly-reduces-errors
    October 30, 2024 - A similar decline occurred in near misses (patients who would have received care intended for someone

  15. Hlthstat (pdf file)

    meps.ahrq.gov/data_stats/nhc/hlthstat.pdf
    September 30, 1997 - If 120 days have not yet occurred, Section HA (T2) will be postponed to Round 3. … Would you say {VARIABLE PART OF QUESTION} did not occur, occurred less than daily, or occurred daily … INCIDENT CONDITIONS HB3 {Was the fracture/Were any of these fractures} the result of a fall that occurred

  16. head-neck-cancer-update-140204 (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/pdf/head-neck-cancer-update_research-protocol.pdf
    February 04, 2014 - association refers to the likelihood that the observed effect is large enough that it cannot have occurred … • Strong: Large effect size that is unlikely to have occurred … absence of a true effect of the intervention • Weak: Small enough effect size that it could have occurred … assembled initially, but some questions remain about whether some (although not major) differences occurred

  17. Urine Culturing Stewardship in the ICU Setting Facilitator Notes (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urine-culturing-notes.docx
    April 01, 2022 - In this case, several harms occurred due to inappropriate culturing of her urine: she was started on

  18. Final Progress Report: Human Factors and Systems Integration in High Technology Surgery (HF-SIgHTS) (pdf file)

    www.ahrq.gov/sites/default/files/2025-07/catchpole-report.pdf
    January 01, 2025 - Across all cases, FDs occurred most frequently during Phase 2 (37.8 ± 16.6 per hr), and least often … Significantly lower rates of severity 2 FDs occurred during Phase 3, where the rate decreased by 50%

  19. Microsoft Word - CaseforPOAIndicator_final_060806 _2_.doc (pdf file)

    hcup-us.ahrq.gov/reports/methods/2006_1.pdf
    January 01, 2006 - reported the indicator as a constant—100% of discharge diagnoses were either present on admission, occurred … codes would provide valuable information regarding whether a patient safety event or medical error occurred

  20. A clinical trial to validate an automated online language interpreting tool with Hispanic patients who have limited English proficiency – Final Report (pdf file)

    digital.ahrq.gov/sites/default/files/docs/citation/r01hs024949-yellowlees-final-report-2022.pdf
    January 01, 2022 - Patient recruitment occurred during years 2 through 6. … It was very slow during year 2 and ceased completely for about 18 months when Covid-19 occurred in years
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