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Total Results: over 10,000 records

Showing results for "occurred".

461. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44929/psn-pdf
     February 08, 2017 - Review of 1574 records from inpatient admissions revealed that adverse events occurred in approximately

462. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37226/psn-pdf
     December 15, 2011 - Parents also did not consistently inform clinicians of ameliorable ADEs when they occurred, leading

463. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44761/psn-pdf
     January 06, 2016 - colors for syringes) following the first event and made further revisions when the second incident occurred

464. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44122/psn-pdf
     January 01, 2016 - The extent of patient harm which occurred or was averted was not reported.

465. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34829/psn-pdf
     April 06, 2011 - METs, which included development and dissemination of objective activation criteria, a 17% decrease occurred

466. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39913/psn-pdf
     October 13, 2010 - Interpretation errors occurred more frequently in children and very elderly patients (older than 85

467. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43799/psn-pdf
     January 07, 2015 - The investigation found that more than half of errors occurred during the administration process, and

468. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34893/psn-pdf
     February 26, 2009 - More than 800 ADEs occurred during the 9-month study period, with nearly 42% deemed preventable.

469. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34670/psn-pdf
     January 01, 2006 - That is, when subjects were informed an outcome had occurred, it biased their hindsight view of events

470. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37648/psn-pdf
     January 12, 2012 - The majority of deaths and hospital transfers occurred in patients undergoing cosmetic procedures, incidents

471. To LP or Not LP | PSNet
     psnet.ahrq.gov/web-mm/lp-or-not-lp
     February 01, 2018 - Fortunately, no long-term sequelae occurred as a consequence of the errors in care suffered by this patient … Four distinct errors occurred in this case. … The errors in execution made by the original provider likely would not have occurred in less hectic working … laboratory could have been more proactive about clarifying information, but had errors one and two not occurred

472. Detecting Med Errors in Rural Hospitals Using Technology - Final Report (pdf file)
     digital.ahrq.gov/sites/default/files/docs/publication/uc1hs015400-brown-final-report-2008.pdf
     January 01, 2008 - Process that reported medication errors occurred by facility Admin­ istering Dis­ pensing Docu­ … Count of where in process the reported medication error occurred Figure 2b. … Count of where in process the reported medication error occurred 0 33 67 100 C ou nt 60 … C o unt o f w here i n pro cess t he reported medication error occurred 0 33 67 100 C ou … Count of where in process the reported medication error occurred 0 33 67 100 C ou nt 30

473. The Nature, Characteristics and Patterns of Perinatal Critical Events Teams (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Riley_58.pdf
     April 02, 2008 - to execute a specific task, whereas “team reformation” occurred when team membership changed in a … Each behavioral marker was scored using the following scale: • “0” Behavior occurred at or below … • “2” Behavior occurred more than 90 percent of the times when prompted by the event set. … emergency measures; and planning for an emergency intervention occurred. … Leadership transfer occurred continuously throughout an obstetrics emergency.

474. Hospitalizations for Circulatory System Disorders, 2004 (pdf file)
     hcup-us.ahrq.gov/datainnovations/clinicaldata/ExampleofUsingPOA-CMSHACsusingall-payerdata.pdf
     July 01, 2011 - following total knee or hip replacement comprised only 8 percent of the ten CMS HACs examined, it occurred … CMS Hospital-acquired conditions by payer Across all of the ten CMS HACs combined, 62 percent occurred … Hospital-acquired conditions by age group Across all of the ten CMS-defined HACs combined, 13 percent occurred … in 18-44 year olds, 32 percent occurred in 45-64 year olds, 44 percent occurred in 65-84 year olds, … and 12 percent occurred in those 85 years and older (data not shown).

475. Statistical Brief #113
     hcup-us.ahrq.gov/reports/statbriefs/sb113.jsp
     May 01, 2011 - for the following types of hospital stays for: complicated pregnancy during which no delivery occurred … Among non-delivery maternal stays, the following conditions occurred at a rate of 100 or more for every … Among maternal stays with delivery, the following conditions occurred at a rate of 50-99 for every 1,000 … Delivery stays Among maternal stays with delivery, the following common complicating conditions occurred … Please note, a discharge of this nature will be included in the NIS if it occurred in a community hospital

476. An Analysis of Nurses' Cognitive Work: A New Perspective for Understanding Medical Errors (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Potter.pdf
     January 01, 2003 - The total number of links was summarized and grouped, then the number of activities that occurred for … Calculations were made to show the cognitive load at the time each interruption occurred and at the … Omissions for RN #3 occurred with a cognitive stacking load of 16, 18, 17, and 16 respectively. … Omissions occurred at various times with respect to a nurse’s cognitive stacking measure. … For example, an omission occurred with a nurse’s cognitive stacking as low as 5 and as high as 20.

477. Preparing for Ambulatory Computerized Prescriber Order Entry by Evaluating Preimplementation Medication Errors (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Devine.pdf
     July 01, 2003 - , but the medication did not reach the patient C An error occurred that reached the patient but did … but no patient harm Error, harm E An error occurred that resulted in the need for treatment or … hospitalization and caused temporary patient harm G An error occurred that resulted in permanent … patient harm H An error occurred that resulted in a near-death event (e.g., anaphylaxis, cardiac … A 5-month time frame was identified; in an effort to minimize bias, one that occurred immediately prior

478. 5. How do you measure fall rates and fall prevention practices? | Agency for Healthcare Research and Quality
     www.qualitymeasures.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/measure-fall-rates.html
     January 01, 2013 - With each fall, you will need to define the level of injury that occurred, if any. … The patient in whom the fall occurred. The date the fall occurred. … But for calculation of a fall rate, you need the date the fall occurred and the responsible unit (if … Rates are calculated as follows: First, count the number of falls that occurred during the month of … Try to understand why the fall occurred and how such an incident might be prevented in the future.

479. 5. How do you measure fall rates and fall prevention practices? | Agency for Healthcare Research and Quality
     preventiveservices.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/measure-fall-rates.html
     January 01, 2013 - With each fall, you will need to define the level of injury that occurred, if any. … The patient in whom the fall occurred. The date the fall occurred. … But for calculation of a fall rate, you need the date the fall occurred and the responsible unit (if … Rates are calculated as follows: First, count the number of falls that occurred during the month of … Try to understand why the fall occurred and how such an incident might be prevented in the future.

480. 5. How do you measure fall rates and fall prevention practices? | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/measure-fall-rates.html
     January 01, 2013 - With each fall, you will need to define the level of injury that occurred, if any. … The patient in whom the fall occurred. The date the fall occurred. … But for calculation of a fall rate, you need the date the fall occurred and the responsible unit (if … Rates are calculated as follows: First, count the number of falls that occurred during the month of … Try to understand why the fall occurred and how such an incident might be prevented in the future.