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Showing results for "occurred".

41. 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.

42. Quality and Safety Review System (QSRS) | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/quality-measures/qsrs/index.html
    April 01, 2025 - the National Academy of Medicine) published To Err Is Human , estimating that up to 98,000 deaths occurred … Human abstractors answer questions to identify whether an adverse event occurred during a particular

43. Dec. 20: Nominations Due for Awards on Best Research Using Healthcare Cost and Utilization Project Data | Agency for Healthcare Research and Quality
    www.ahrq.gov/news/hcup-data-awards.html
    November 01, 2024 - Publications must have occurred between July 1, 2022, and June 30, 2024.

44. 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

45. High Rates of Adverse Drug Events in a Highly Computerized Hospital | AHRQ Digital Healthcare Research: Informing Improvement in Care Quality, Safety, and Efficiency
    digital.ahrq.gov/health-it-tools-and-resources/health-it-bibliography/patient-safety/high-rates-adverse-drug-events
    July 19, 2021 - We describe the frequency and type of inpatient ADEs that occurred following the adoption of multiple … Medication errors associated with ADEs occurred in the following stages: 61% ordering, 25% monitoring

46. 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.

47. 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

48. 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

49. 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.

50. 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, 2022 - 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

51. 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.

52. New Interactive Data Resource Illustrates Trends in Sepsis Hospital Care | Agency for Healthcare Research and Quality
    www.ahrq.gov/news/newsletters/e-newsletter/949.html
    March 01, 2025 - aureus (MRSA) decreased by nearly 11 percent between 2016 and 2021, rates of MRSA infections that occurred … therapy with 67,046 patients who received early broad-spectrum therapy, the authors found that death occurred … In contrast, after early treatment, death occurred in 9.5 percent of cases, adverse drug events in 7.2

53. 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

54. Morningbriefing (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/morningbriefing.doc
    August 07, 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. II.

55. 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

56. 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

57. 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

58. 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.

59. 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.

60. 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