Results

Total Results: over 10,000 records

Showing results for "occurred".

81. The patients' perspective: hematological cancer patients' experiences of adverse events as part of care. | PSNet
    psnet.ahrq.gov/issue/patients-perspective-hematological-cancer-patients-experiences-adverse-events-part-care
    December 01, 2019 - 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

82. Identifying health information technology usability issues contributing to medication errors across medication process stages. | PSNet
    psnet.ahrq.gov/issue/identifying-health-information-technology-usability-issues-contributing-medication-errors
    November 03, 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.

83. Use of a computerized guideline for glucose regulation in the intensive care unit improved both guideline adherence and glucose regulation | AHRQ Digital Healthcare Research: Informing Improvement in Care Quality, Safety, and Efficiency
    digital.ahrq.gov/health-it-tools-and-resources/health-it-costs-and-benefits-database/use-computerized-guideline
    August 16, 2021 - Changes in efficiency and productivity:  Late glucose measurement occurred 66% of the time in the first … In the second period, it occurred 42% for the paper-bease and only 28% for the computer-based sample.

84. Statistical Brief #147: Emergency Department Visits and Hospital Inpatient Stays for Seasonal and 2009 H1N1 Influenza, 2008-2009 (pdf file)
    hcup-us.ahrq.gov/reports/statbriefs/sb147.pdf
    March 01, 2012 - ■ ED visits for influenza occurred at a rate of 417.5 per 100,000 population in 2009 compared to … Hospitalizations for influenza occurred at a rate of 53.1 per 100,000 population in 2009 compared to … 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). … During the second wave of the 2009 H1N1 pandemic, which occurred in the 2009–2010 influenza season

85. 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

86. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/vae/objective-outcome-tool.docx
    January 01, 2017 - Total number of episodes of mechanical ventilation How many episodes of mechanical ventilation have occurred … Total number of deaths How many deaths have occurred in the patients who have been or were mechanically

87. Hospital Evacuation Decision Guide | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/shuttered/hospevac4.html
    July 01, 2018 - Post-Event Evacuation Decision Guide Post-event evacuations have occurred either following Advanced … Sequence in a Post-Event Evacuation If the decision is made to begin an evacuation after the event has occurred … filled with water from the nearby Haw Creek and power was lost. 53 The full evacuation of 157 patients occurred

88. Final Progress Report: Evaluation of Risk by Active Surveillance in the Emergency Department (ERASED) (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/hall1-report.pdf
    January 01, 2024 - events were categorized into two taxonomies: (1) the segment of emergency care in which the event occurred … Patient visits were eligible for inclusion if (1) the visit occurred in the adult emergency department … An additional category, transitions, was added to account for periods when an event occurred during … The nonideal care events were categorized into the segment of care in which they occurred (Figure 1) … Significant time was spent distinguishing the true process from workarounds, which occurred between

89. Relationships between medications used in a mental health hospital and types of medication errors: a cross-sectional study over an 8-year period. | PSNet
    psnet.ahrq.gov/issue/relationships-between-medications-used-mental-health-hospital-and-types-medication-errors
    November 29, 2023 - This study used 8 years of medication records to identify when in the medication process the error occurred … Nearly one-third of errors were wrong dose and occurred in the prescribing stage.

90. Omission of high-alert medications: a hidden danger. | PSNet
    psnet.ahrq.gov/issue/omission-high-alert-medications-hidden-danger
    January 11, 2017 - The investigation found that more than half of errors occurred during the administration process, and … September 27, 2016 External Inquiry into the adverse incident that occurred at Queen's

91. 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

92. Practice Self-Assessment Tool for Opioid Use in Older Adults (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/opioids/compendium/opioids-compendium-self-assessment.pdf
    December 01, 2023 - .) … …has never or very rarely occurred. … …has occurred sporadically in the past but there have been no recent updates. … …has occurred recently but has not resulted in changes in care for older adults with chronic pain. … …has occurred recently and has prompted changes in the care provided to older adults with chronic … …has occurred but without any follow-up discussions or application to patient care.

93. Evaluation of Medications Removed from Automated Dispensing Machines Using the Override Function Leading to Multiple System Changes (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Miller_93.pdf
    March 12, 2008 - The authors explained that these problems occurred when the pharmacy was closed and when all medications … Of the 59 instances of override, 17 (28.8 percent) occurred during a first shift (7:00 am to 3:30 pm … ); 31 (52.5 percent) occurred during a second shift (3:00 pm to 11:30 pm); and 11 (18.6 percent) occurred … Forty-five overrides (76.3 percent) occurred on weekdays. … The largest number of overrides occurred during the second shift, which was also when the majority of

94. NPSD Data Spotlight - Patient Safety and COVID-19: A Qualitative Analysis of Concerns During the Public Health Emergency (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-ptsafety-and-covid-19.pdf
    November 01, 2021 - There is no evidence in these reports that any other type of patient safety concern occurred. … In several instances, the exposure occurred because staff were not following PPE protocols, such as … In other cases, the exposure occurred with an asymptomatic individual, and was later identified when … Additional near misses occurred when the wrong blood product (e.g., fresh frozen plasma versus COVID … PSOs generally provided data elements for the location in the facility where the event occurred and

95. 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

96. 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

97. Summary Skills Practice Exercise Sheet (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module7/ts2-0ltc_module7_ig_summary_exsheet.pdf
    April 24, 2017 - Identify the instances where a breakdown in teamwork has occurred as it relates to the specific teamwork … SCENARIO: A gastrointestinal outbreak has occurred within the nursing home and has affected the entire

98. A computerized intervention to improve timing of outpatient follow-up: a multicenter randomized trial in patients treated with warfarin. National Consortium of Anticoagulation Clinics | AHRQ Digital Healthcare Research: Informing Improvement in Care Quality, Safety, and Efficiency
    digital.ahrq.gov/health-it-tools-and-resources/health-it-costs-and-benefits-database/computerized-intervention
    March 01, 1994 - Life-threatening complications occurred in the care of three experimental patients and one control patient … , while other serious complications occurred in the care of 16 experimental patients and 17 control patients

99. 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

100. National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data From National Efforts To Make Health Care Safer | Agency for Healthcare Research and Quality
     www.cahps.ahrq.gov/hai/pfp/2015-interim.html
     December 01, 2016 - over the 5 years (2011, 2012, 2013, 2014, and 2015) 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 2015 than would have occurred if the rate of HACs had remained steady at the 2010 level ( Exhibit … Cumulatively, approximately 3.1 million fewer incidents of harm occurred in 2011, 2012, 2013, 2014, and … on October 1, 2015, and also due in part to delays in contracting for MPSMS data analysis that occurred