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Showing results for "occurred".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35050/psn-pdf
    May 27, 2011 - The majority of errors that resulted in an ADE occurred in the medication ordering phase.

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36409/psn-pdf
    September 28, 2016 - Using a high-paced emergency department (ED) setting, investigators discovered that interruptions occurred

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38515/psn-pdf
    March 03, 2011 - Most errors occurred during drug administration. 

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34795/psn-pdf
    December 23, 2008 - The authors also present data on the stage at which an ADE occurred, consequences of the preventable

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46134/psn-pdf
    September 24, 2017 - Many of these errors occurred during the transition home after hospital discharge.

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36784/psn-pdf
    February 24, 2011 - many-faces-error-disclosure-common-set-elements-and-definition When medical errors occur, patients desire full disclosure about the error and why it occurred

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42933/psn-pdf
    July 03, 2014 - critical-events-during-land-based-interfacility-transport In this retrospective cohort study, critical events occurred

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34698/psn-pdf
    January 04, 2017 - process can fail, prioritize those failure modes, and take corrective action before failures have occurred

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38758/psn-pdf
    July 08, 2009 - overall incidence of errors appears low, most reported errors were considered preventable, as they occurred

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46359/psn-pdf
    September 21, 2017 - reported miscommunications, and those parents were more likely to also perceive that an adverse event occurred

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35134/psn-pdf
    June 22, 2009 - However, the authors point out that even at hospitals with METs in place, inadequate utilization occurred

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37346/psn-pdf
    March 28, 2012 - inpatient CPOE did not prevent medication administration discrepancies, and delays of nearly 30 minutes occurred

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43173/psn-pdf
    June 04, 2014 - A past AHRQ WebM&M commentary discussed a serious error that occurred after a liposuction procedure

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40921/psn-pdf
    November 16, 2011 - Joint Commission and for failing to monitor long-term safety performance at hospitals where errors occurred

  15. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits - Functional Specifications (pdf file)

    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallspxspecs.pdf
    February 01, 2018 - type occurred daily. … type occurred daily. … type occurred daily. … type occurred daily. … type occurred daily.

  16. Improving the Safety of Heparin Administration by Implementing a Human Factors Process Analysis (pdf file)

    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Harder.pdf
    May 19, 2003 - Brennan et al.1 reported that adverse events occurred in 3.7 percent of the selected cases (95% confidence … Thomas et al.2 reported that in this sample, adverse events occurred at a rate of 2.9 percent (with … Death occurred in 6.6 percent (SD of 1.2 percent) of the adverse events. … in 2003.4 Not surprisingly, the results of the studies of adverse events that occurred in Utah and … This education occurred on the patient care units 24 hours a day for the 5-day process.

  17. PowerPoint Presentation

    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module6/module6-care-for-caregiver.pptx
    May 01, 2011 - , but they feared that an error may have occurred. … /organization recognizing event occurred. … This stage is characterized by either the second-victim realizing that an event has occurred, or the … organization recognizing that an event has occurred. … The event might produce feelings of internal inadequacy, either because the event occurred or because

  18. Event Investigation and Analysis Guide: Appendix C | Agency for Healthcare Research and Quality

    pbrn.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apc.html
    August 01, 2022 - This format helps to utilize the information found in the investigation to understand why the event occurred

  19. Event Investigation and Analysis Guide: Appendix C | Agency for Healthcare Research and Quality

    pcmh.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apc.html
    August 01, 2022 - This format helps to utilize the information found in the investigation to understand why the event occurred

  20. PowerPoint Presentation

    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/module5-response-disclosure-notes.pptx
    August 21, 2015 - The patient and/or family have a reasonable expectation to be informed when a harm event has occurred … of this initial conversation is to advise the patient and/or family that an adverse event may have occurred … Investigation and Analysis, the disclosure should include – An explicit statement that an event has occurred … During disclosure, patients and families generally want a clear, explicit statement that an event has occurred … If the event was preventable and occurred due to error, the communicator should: Consider using the word
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