Results

Total Results: over 10,000 records

Showing results for "occurred".

81. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/42968/psn-pdf
    February 26, 2014 - 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

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

83. Module 5: Response and Disclosure | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/notes.html
    August 01, 2022 - 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 … During disclosure, patients and families generally want a clear, explicit statement that an event has occurred … what happened in a way that is easy to understand, explain what is known about why the adverse event occurred … If the event was preventable and occurred due to error, the communicator should: Consider using

84. Module 4: Event Reporting, Event Investigation and Analysis | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes4.html
    August 01, 2022 - information, other than event reports, that might provide information indicating that a CANDOR event has occurred … create a cohesive environment for informing the organization as to whether a CANDOR event may have occurred … implement the best practice of creating a hotline for staff to call when they feel a CANDOR event has occurred … Risk Management can also provide ongoing support to managers on the unit(s) where the event occurred. … Also, the location where the event occurred is generally no longer intact, so information that could

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

86. Multimodal system designed to reduce errors in recording and administration of drugs in anaesthesia: prospective randomised clinical evaluation. | PSNet
    psnet.ahrq.gov/issue/multimodal-system-designed-reduce-errors-recording-and-administration-drugs-anaesthesia
    September 26, 2012 - Although fewer overall errors occurred with the new system, the reduction in administration errors occurred

87. Adverse Events, Near Misses, and Errors | PSNet
    psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors
    March 30, 2022 - independently reviewed by two clinically experienced reviewers in order to determine whether an adverse event occurred … When an adverse event occurred, reviewers also may disagree about whether the event was preventable. … Important subcategories of adverse events include: Preventable adverse events : those that occurred due … could have been less harmful if care had been different; Adverse events due to negligence : those that occurred

88. Final Progress Report: Developing biomechanical models from initiated fall actions and reactions in frail elderly patients (pdf file)
    www.ahrq.gov/sites/default/files/2024-07/morse-merryweather-report.pdf
    January 01, 2024 - The majority of FREs occurred in the Stand and Gait phases (n = 45 and 33, respectively). … Twenty-eight FREs occurred in Stand Preparation through the Stand Phase, FREr; 18 FREs occurred during … The shortest duration occurred in the Gait Initiation Subphase: 1.32 (0.58) seconds. … The majority of FREs occurred during rising. … The majority of the 61 FREs occurred during rising.

89. Final Progress Report: Blood Product Transfusion & Safe Practices (pdf file)
    www.ahrq.gov/sites/default/files/2024-02/herwaldt-report.pdf
    January 01, 2024 - Identification Errors 4/21/04 – 2/07/05 (Pilot Period) Prevented Errors Count Step/ Occurred Step … Skipped steps occurred when the nurse or phlebotomist failed to scan -10- the patient’s barcoded … Skipped steps often occurred because personnel within the Critical Care Laboratory failed to complete … Skipped steps during administration occurred when the transfusionist failed to complete all three scans … This occurred at night in an intensive care unit shortly after the system was activated.

90. A Comparison of All-Cause 7-Day and 30-Day Readmissions, 2014 (pdf file)
    hcup-us.ahrq.gov/reports/statbriefs/sb230-7-Day-Versus-30-Day-Readmissions.pdf
    December 01, 2016 - For diagnoses with the highest 7-day readmission rates, the percentage of 30-day readmissions that occurred … More than one-third of these readmissions occurred within 7 days, reflecting a 7-day readmission rate … Overall, 36.1 percent of all 30-day readmissions occurred within 7 days. … Across payers, the percentage of 30-day readmissions that occurred within 1 week of initial discharge … In comparison, 31–32 percent of 30-day readmissions for CHF occurred within 7 days across payers.

91. Final Progress Report: Developing and Training Interruption Management Strategies for Emergency Physicians (pdf file)
    www.ahrq.gov/sites/default/files/2024-09/ratwani-report.pdf
    January 01, 2024 - tasks physicians were engaged in on a second-by-second basis and to document the when interruptions occurred … • The location of where the interruption occurred was recorded as being at the workstation, in the … Consequently, we could not observe any interruptions that occurred in patient rooms. … Rejecting interruptions occurred only 1.3% of the time (n = 6 occurrences). … source of the interruptions and the primary tasks that were being performed when the interruptions occurred

92. HAC National Scorecard 2014-16 (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac-scorecard-2014-16.pdf
    January 01, 2014 - HAC National Scorecard 2014-16 Between 2014-2016, 350,000 fewer hospital-acquired conditions (HACs) occurred

93. Chapter 9. Potential Future Uses of the Data Infrastructure | Agency for Healthcare Research and Quality
    www.ahrq.gov/practiceimprovement/delivery-initiative/ihs/chapter9.html
    December 01, 2017 - following the visit may be used to assess if laboratory testing, medication changes, and ECM service use occurred … If such service use occurred following the visit, the office visit may be classified as a clinical opportunity

94. Mitchell E et al. 2001 "A descriptive feast but an evaluative famine: systematic review of published articles on primary care computing during 1980-97." | Digital Healthcare Research
    digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/mitchell-e-et-al-2001
    January 01, 2001 - Again the largest increase occurred with an electronic protocol, and consultation length increased by … The greatest increases occurred when physicians were prompted as part of the consultation." … The greatest improvement in disease management "occurred when physicians used an electronic protocol,

95. 023-Ss-Cusp-Learning-From-Defects-Fg (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/023-ss-cusp-learning-from-defects-fg.docx
    April 01, 2025 - Even if the MRSA detection represents colonization and no infections have occurred, this indicates an … infection prevention lapse occurred, and the patient is at increased risk of developing a MRSA infection … · What actions occurred? · What were people thinking and feeling? … · What else was happening at the time the defect occurred? … The CUSP team found that after implementing the interventions, no MRSA SSI infections occurred in the

96. Disclosure Checklist | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/checklist5.html
    August 01, 2022 - after the CANDOR event is identified, advise the patient and/or family that an adverse event may have occurred … Explain what is known about why the adverse event occurred; do not speculate.  

97. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/49395/psn-pdf
    April 01, 2003 - references additional 5% experience a potential ADE (ie, the error reached the patient, but no harm occurred … reported similar rates of ADEs, though rates of potential ADEs were even higher.(5) Most potential ADEs occurred … (Figure 1, Figure 2) The error in this case occurred independent of prescription legibility. … confusion between ‘dose’ and ‘day,’ due to ambiguous use of the abbreviation “d” in “mg/kg/d,” could have occurred … ensures that orders are complete and in a standard format, eliminating ambiguous dosing orders as occurred

98. AHRQ Mastectomy SB Infographic v15 (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/double-mastectomy.pdf
    February 01, 2016 - The rise in mastectomies occurred despite breast cancer rates remaining constant. 2005 2013 Sharp

99. A Comparison of All-Cause 7-Day and 30-Day Readmissions, 2014 #230
    hcup-us.ahrq.gov/reports/statbriefs/sb230-7-Day-Versus-30-Day-Readmissions.jsp
    October 01, 2017 - More than one-third of these readmissions occurred within 7 days, reflecting a 7-day readmission rate … Timing of readmissions, 2014 Figure 1 displays the percentage of 30-day readmissions that occurred … Over one-third of 30-day readmissions occurred within the first 7 days following discharge. … Overall, 36.1 percent of all 30-day readmissions occurred within 7 days. … Across each expected payer, slightly more than one-third of 30-day readmissions occurred within 7 days

100. Abt Single-Sided Body Template (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallpxsamplereports.docx
     June 02, 2025 - within the facility’s electronic medical record, such as nurse assessments, and represent changes that occurred … Summary of Fall Risk Factors Report is a count of risk factors associated with the falls that have occurred … For each month, it displays the number of falls that occurred and the risk factors associated with … each fall with fall date prior to and within 30 days of report date: Day of week on which the fall occurred … , Shift during which the fall occurred, Time at which the fall occurred, The location of the fall, and