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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. 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

83. 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

84. 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).

85. 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

86. 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

87. 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.

88. 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

89. 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.

90. 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

91. 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

92. 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.

93. 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

94. 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

95. 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

96. 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.

97. 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.

98. 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

99. 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.

100. 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.