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Showing results for "occurred".

  1. Infographic Poster: Did you know...Patient safety issues in primary care are real. (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/patient-safety-issues.pdf
    May 21, 2020 - Infographic Poster: Did you know...Patient safety issues in primary care are real. Did you know... Patient safety issues in primary care are real. Annually, 1 in 20 outpatients experiences a diagnostic error 55% of patients said diagnostic errors were a chief concern in outpatient visits 1 in 9 ED admissi…

  2. Implementing human factors in anaesthesia: guidance for clinicians, departments and hospitals: Guidelines from the Difficult Airway Society and the Association of Anaesthetists. | PSNet

    psnet.ahrq.gov/issue/implementing-human-factors-anaesthesia-guidance-clinicians-departments-and-hospitals
    February 15, 2023 - Organizational Policy/Guidelines Implementing human factors in anaesthesia: guidance for clinicians, departments and hospitals: Guidelines from the Difficult Airway Society and the Association of Anaesthetists. Citation Text: Kelly FE, Frerk C, Bailey CR, et al. Implementing human factor…

  3. Refining a framework to enhance communication in the emergency department during the diagnostic process: an eDelphi approach. | PSNet

    psnet.ahrq.gov/issue/refining-framework-enhance-communication-emergency-department-during-diagnostic-process
    May 08, 2024 - Study Refining a framework to enhance communication in the emergency department during the diagnostic process: an eDelphi approach. Citation Text: Manojlovich M, Bettencourt AP, Mangus CW, et al. Refining a framework to enhance communication in the emergency department during the diagnos…

  4. 037-Ss-Bed-Bathing-Chg-Cloths-Protocol (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/037-ss-bed-bathing-chg-cloths-protocol.docx
    April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI Pre-Op Surgical Decolonization Protocol for Staff: Bathing With 2 Percent Chlorhexidine No-Rinse Cloths Surgical Services For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries The following protocol details the process for performing skin decol…

  5. Patient falls in the operating room: why is this still a problem in 2024? | PSNet

    psnet.ahrq.gov/issue/patient-falls-operating-room-why-still-problem-2024
    May 08, 2024 - Commentary Patient falls in the operating room: why is this still a problem in 2024? Citation Text: Pellegrino A, Brook K. Patient falls in the operating room: why is this still a problem in 2024? J Patient Saf. 2024;20(6):e87-e90. doi:10.1097/pts.0000000000001248. Copy Citation Fo…

  6. From research to practice: factors affecting implementation of prospective targeted injury-detection systems. | PSNet

    psnet.ahrq.gov/issue/research-practice-factors-affecting-implementation-prospective-targeted-injury-detection
    August 04, 2021 - Study From research to practice: factors affecting implementation of prospective targeted injury-detection systems. Citation Text: Sorensen A, Harrison MI, Kane HL, et al. From research to practice: factors affecting implementation of prospective targeted injury-detection systems. BMJ …

  7. Surgical never events in the United States. | PSNet

    psnet.ahrq.gov/issue/surgical-never-events-united-states
    September 10, 2014 - Study Surgical never events in the United States. Citation Text: Mehtsun WT, Ibrahim AM, Diener-West M, et al. Surgical never events in the United States. Surgery. 2013;153(4):465-472. doi:10.1016/j.surg.2012.10.005. Copy Citation Format: DOI Google Scholar PubMed BibTeX …

  8. Controlled substance drug diversion by healthcare workers as a threat to patient safety. | PSNet

    psnet.ahrq.gov/issue/controlled-substance-drug-diversion-healthcare-workers-threat-patient-safety
    April 05, 2023 - Special or Theme Issue Controlled substance drug diversion by healthcare workers as a threat to patient safety. Citation Text: Controlled substance drug diversion by healthcare workers as a threat to patient safety. ISMP Medication Safety Alert! Acute care edition. February 23, 2023;28(4…

  9. Registered nurses' judgments of the classification and risk level of patient care errors. | PSNet

    psnet.ahrq.gov/issue/registered-nurses-judgments-classification-and-risk-level-patient-care-errors
    August 24, 2022 - Study Registered nurses' judgments of the classification and risk level of patient care errors. Citation Text: Chipps E, Wills CE, Tanda R, et al. Registered nurses' judgments of the classification and risk level of patient care errors. J Nurs Care Qual. 2011;26(4):302-310. doi:10.1097…

  10. Potentially inappropriate medication use and healthcare expenditures in the US community-dwelling elderly. | PSNet

    psnet.ahrq.gov/issue/potentially-inappropriate-medication-use-and-healthcare-expenditures-us-community-dwelling
    April 08, 2020 - Study Potentially inappropriate medication use and healthcare expenditures in the US community-dwelling elderly. Citation Text: Fu AZ, Jiang JZ, Reeves JH, et al. Potentially inappropriate medication use and healthcare expenditures in the US community-dwelling elderly. Med Care. 2007;4…

  11. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-05/final_may-spotlight-fatal_pca_slides_05.01.2020_cme_review-revised.pdf
    January 01, 2020 - opioid-induced respiratory depression; of those, 77% resulted in severe brain damage or death – Most injuries occurred

  12. Methods Future Research Needs Number 8: Framework for Considering Study Designs (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/pdf/study-design-framework_research.pdf
    March 01, 2012 - This is a retrospective study that collects data on events that have already occurred. 7 Advantages

  13. Methods Future Research Needs Number 8: Framework for Considering Study Designs (pdf file)

    effectivehealthcare-admin.ahrq.gov/sites/default/files/pdf/study-design-framework_research.pdf
    March 01, 2012 - This is a retrospective study that collects data on events that have already occurred. 7 Advantages

  14. SRDR - Systematic Review Data Repository |

    srdr.ahrq.gov/projects/1696
    July 01, 2020 - uterine infection were small and not statistically significant (SOE: low), and while shoulder dystocia occurred

  15. AHRQ - Quality Indicators

    qualityindicators.ahrq.gov/Archive/News2009.aspx
    January 27, 2010 - Beta testing has occurred with many QI users and other external parties.

  16. Comparative Effectiveness Review No. 234 Evidence Summary: Management of Primary Headaches in Pregnancy (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/cer-234-headaches-pregnancy-summary.pdf
    November 01, 2020 - No serious maternal adverse effects occurred (low SoE).

  17. Implement Teamwork and Communication for Perinatal Safety | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/tools/perinatal-care/modules/teamwork/implement-slides.html
    May 01, 2017 - Slide 17: Feedback 2 Timely—given soon after the target behavior has occurred.

  18. Pocket Guide: TeamSTEPPS: Strategies & Tools to Enhance Performance and Patient Safety (pdf file)

    www.qualitymeasures.ahrq.gov/sites/default/files/publications/files/pocketguide.pdf
    January 01, 2020 - improving team performance Feedback should be: • Timely – given soon after the target behavior has occurred

  19. Pocket Guide: TeamSTEPPS: Strategies & Tools to Enhance Performance and Patient Safety (pdf file)

    teamstepps.ahrq.gov/sites/default/files/publications/files/pocketguide.pdf
    January 01, 2020 - improving team performance Feedback should be: • Timely – given soon after the target behavior has occurred

  20. Pocket Guide: TeamSTEPPS: Strategies & Tools to Enhance Performance and Patient Safety (pdf file)

    talkingquality.ahrq.gov/sites/default/files/publications/files/pocketguide.pdf
    January 01, 2020 - improving team performance Feedback should be: • Timely – given soon after the target behavior has occurred
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