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Showing results for "occurred".

61. Final Progress Report: Pediatric Medication Safety: Analyses from the MEDMARX Medication Error Reporting System (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/bundy-report.pdf
    January 01, 2024 - Categories E through H errors not only occurred and reached the patient but also caused harm. … In one study of nationally representative US data, extra vaccination occurred in 21% of young children … Harmful errors occurred with all cardiovascular drug classes. … However, because over half the errors occurred at the administering stage of medication processing, … Not surprisingly, a large majority of reported pediatric antidepressant medication errors occurred

62. Appendix G. Safety and Adverse Events | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/universal-icu-decolonization/universal-icu-apg.html
    September 01, 2013 - difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue), but it has occurred

63. Final Progress Report: Medication Error Reduction, Technologies and Human Factors (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/carayon-report.pdf
    January 01, 2024 - The pump observations occurred 1 month before Smart IV pump implementation and 5 months 4 after … Forty-six hours of meeting time occurred over 4.5 months, representing 600 person-hours of time. … The second round of usability testing occurred with what was ultimately the final pump. … There were nine different units and the emergency department on which the observations occurred. … Staff were unaware and surprised that an UNDER- infusion most likely occurred in these cases.

64. Statistical Brief #147
    hcup-us.ahrq.gov/reports/statbriefs/sb147.jsp
    January 01, 2013 - ED visits for influenza occurred at a rate of 161.8 per 100,000 population in 2008 compared to 417.5 … ED visits for influenza occurred at a rate of 417.5 per 100,000 population in 2009 compared to 161.8 … In 2008, peak activity occurred in February (79.9 ED visits per 100,000 population). … In 2009, peak activity occurred in October (125.2 ED visits per 100,000 population). … *The rates are based on hospitalizations that occurred September through March (influenza season).

65. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/40819/psn-pdf
    January 07, 2015 - Although fewer overall errors occurred with the new system, the reduction in administration errors occurred

66. Appendix G. Safety and Adverse Events | Agency for Healthcare Research and Quality
    www.ahrq.gov/es/hai/universal-icu-decolonization/universal-icu-apg.html
    September 01, 2013 - difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue), but it has occurred

67. Final Progress Report: Brief, Risky, High-Benefit Procedures: Best Practice Model (pdf file)
    www.ahrq.gov/sites/default/files/2024-02/mackenzie-report.pdf
    January 01, 2024 - No operator injuries occurred with a redesigned instrument tray. … Complications of CTI in one study of 426 consecutive patients occurred in 21%. … Undrained pneumothorax, hemothorax, or effusion despite CTI occurred in 35 patients. … In one of these patients, the air re-accumulation occurred after hospital discharge. … In one patient, this occurred 5 days after hospital discharge (Fig. 5).

68. Telehealth and Emergency Medicine: A Consensus Conference to Map the Intersection of Emergency Medicine and Telehealth - Final Report (pdf file)
    digital.ahrq.gov/sites/default/files/docs/citation/r13hs027528-clark-final-report-2021.pdf
    January 01, 2021 - Co-chairs reviewed the summaries and ensured no overlap occurred. … The sixth step occurred on Day 1 of the virtual conference. … The seventh step occurred on Day 2 of the conference. … The eighth step occurred after the conference. … Round 2 of the voting occurred after the first conference day, and round 3 occurred live in the second

69. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/36342/psn-pdf
    March 02, 2011 - Diagnostic errors resulting in patient harm occurred in 181 cases, chiefly consisting of missed or delayed … As with prior studies  using chart review, reviewer's agreement on whether an error occurred was only

70. From physician intent to the pharmacy label: prevalence and description of discrepancies from a cross-sectional evaluation of electronic prescriptions. | PSNet
    psnet.ahrq.gov/issue/physician-intent-pharmacy-label-prevalence-and-description-discrepancies-cross-sectional
    July 22, 2020 - The investigators found that errors occurred at each stage of the process, with a small but significant … These errors often occurred when providers entered free-text instructions into the e-prescribing system

71. How useful are voluntary medication error reports? The case of warfarin-related medication errors. | PSNet
    psnet.ahrq.gov/issue/how-useful-are-voluntary-medication-error-reports-case-warfarin-related-medication-errors
    May 27, 2011 - Investigators discovered that inpatient warfarin-related errors occurred most frequently during transcription … /documentation and administration, while outpatient errors occurred most frequently during prescribing

72. Choosing your words carefully: how physicians would disclose harmful medical errors to patients. | PSNet
    psnet.ahrq.gov/issue/choosing-your-words-carefully-how-physicians-would-disclose-harmful-medical-errors-patients
    February 16, 2011 - Prior research revealed that patients wanted the physicians to apologize for the error, explain how it occurred … Approximately half of respondents declined to explain how the error occurred or discuss specific plans

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

74. AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention Training | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/reportguide.html
    November 01, 2017 - It displays the number of falls that occurred and the risk factors associated with the falls. … For each of the months (1 or 3) included in the report, any fall that occurred before the report date … For each of the months (1 or 3) included in the report, any fall that occurred before the report date … For each of the months (1 or 3) included in the report, any fall that occurred before the report date … , Shift during which the fall occurred, Time at which the fall occurred, The location of the fall

75. S89 (pdf file)
    effectivehealthcare.ahrq.gov/sites/default/files/s89.pdf
    October 01, 2007 - in the vaccinated group, whereas 1 had occurred in the control group (Table 1). … At week 12, 2 cases occurred in the vaccinated group compared with no cases in the control group, for … A third case occurred in the vaccinated group during week 14, with an increase in LLR to 2.08. … Hypothetically, the LLR would have been different if the fourth case of facial paralysis had occurred … If 3 cases had occurred during week 12, the LLR would have been 7.86, exceeding the critical value at

76. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.239_slideshow.ppt
    May 01, 2011 - Disclosure Discussing medical errors with patients is challenging Patients want to know when errors have occurred … Disclosure respects patient autonomy In general, patients want to learn about harmful errors that have occurred … Additional factors complicate this case: The disclosing physicians did not make the error The error occurred … the care provided Examination of the possible error might involve a root cause analysis If an error occurred … two hospitals should have had an open dialogue about the case If they determined that a clear error occurred

77. The Nature, Characteristics and Patterns of Perinatal Critical Events Teams (pdf file)
    www.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.

78. Risk Assessment | Digital Healthcare Research
    digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/risk
    January 01, 2023 - The process can be used to study a failure that actually occurred, or it could study a potential failure … Description Root cause analysis (RCA) is a popular technique used to determine why a problem occurred

79. Preparing for Ambulatory Computerized Prescriber Order Entry by Evaluating Preimplementation Medication Errors (pdf file)
    www.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

80. An Analysis of Nurses' Cognitive Work: A New Perspective for Understanding Medical Errors (pdf file)
    www.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.