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Total Results: 596 records

Showing results for "occurrence".

101. AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/3.html
     December 01, 2017 - Displays the occurrence of a resident weight loss of ≥5% compared to weight closest to 30 days prior.

102. A Model-based Approach to Prioritizing Medical Safety Practices (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Marken.pdf
     January 01, 2004 - fact that human error is a main contributor to many industrial incidents, such as the near-meltdown occurrence … that identifies not only the causes of human error, but also the reasons behind the rate of error occurrence … prescribing model shown in Figure 1 by testing its ability to account for existing data on the rate of occurrence … Studies by Leape, et al37 and Lesar, et al8 determined the rate of occurrence for several different … Table 2 represent various error-reduction practices that have been proposed as a means of reducing the occurrence

103. Common Cause Analysis: Focus on Institutional Change (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Browne_5.pdf
     January 20, 2008 - Themes are then prioritized by scoring for severity, occurrence, and detectability. … Each theme was scored in three categories – severity, occurrence, and detectability. … • Occurrence (O) evaluates the risk of the event occurring again. … inter-rater reliability, each RCA Clinical Process Manager independently scored each theme for severity, occurrence … Process Managers then engaged in a discussion to assure that individual scores truly reflected severity, occurrence

104. 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/vae-tool.docx
     January 01, 2017 - Facilitator Guide: Build Your SSI Prevention Bundle AHRQ Safety Program for Mechanically Ventilated Patients Ventilator-Associated Event Data Collection Tool Date __________ Month __________ Hospital __________ Unit __________ Use this tool to track your progress i…

105. Adolescent Depression Remission/Response Measure Description (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/depression/chipra-247-section-2.pdf
     June 02, 2025 - related PHQ-9 score greater than 9 The initial PHQ-9 or PHQ-A score greater than 9 is the earliest occurrence

106. Ambulatory Surgery Center Survey on Patient Safety Culture: Composites and Items (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/composite-measures-english.pdf
     January 01, 2015 - something happens that could harm the patient, but does not, how often is it documented in an incident or occurrence

107. University of Missouri Health Care Decreases Pressure Injuries and Saves in Avoidable Costs | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/about/uni-missouri-healthcare.html
     February 01, 2024 - All-cause HAPI rates and PSI-03 were sustained at a higher- than-expected occurrence, which has a negative

108. Diagnostic Stewardship Interventions To Reduce Diagnostic Error | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-dx-stewardship5.html
     August 01, 2024 - promote optimal use of diagnostic tests, improve the speed and accuracy of diagnosis, and reduce the occurrence

109. Surveys on Patient Safety Culture (SOPS) Ambulatory Surgery Center Survey: 2023 User Database Report Part II (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/2023-ASC-Database-Report-II.pdf
     January 01, 2023 - indicated that near-miss incidents were “Always” or “Most of the time” documented in an incident or occurrence … indicated that near-miss incidents were “Always” or “Most of the time” documented in an incident or occurrence … indicated that near-miss incidents were “Always” or “Most of the time” documented in an incident or occurrence … happens that could harm the patient, but does not, how often is it documented in an incident or occurrence … happens that could harm the patient, but does not, how often is it documented in an incident or occurrence

110. Objective Outcomes Data Collection Tool | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/modules/vae/objective-outcome-tool.html
     January 01, 2017 - Objective Outcomes Data Collection Tool AHRQ Safety Program for Mechanically Ventilated Patients Hospital ___________            Unit___________                   Month ___________ Please record the following occurrences for all patients in your unit within the selected month. ________ Total…

111. 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 - Introduction The occurrence of medical errors within the acute care environment, as reported in To … A spreadsheet with each physical activity and the time of occurrence was developed to create a task … The bottom horizontal row of vertical arrows and designated times shows the occurrence of interruptions

112. Observing Nurse Interaction with Infusion Pump Technologies (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Carayon.pdf
     January 01, 2004 - process charts; (5) Gantt charts; (6) multiple activity charts; (7) link charts; and (8) occurrence … nursing tasks, track motions and physical connections, and identify heavy traffic patterns.7, 8 In occurrence … medication use process, identifying failure modes, and estimating the likelihood of failure mode occurrence … The location of occurrence of each step in the process is recorded with an alphabetical abbreviation … Next, observations were used to confirm the occurrence of failure modes on a day-to- day basis.

113. References (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/subglottic-litreview.docx
     January 01, 2017 - Ventilator-associated condition occurrence did not differ between the two groups and appeared to be related … Findings showed that the occurrence of VAP could be significantly delayed with the use of continuous … reviewed 12 original articles and 4 reviews that evaluated the effectiveness of SSD in reducing the occurrence … The occurrence of VAP can be significantly delayed among patients undergoing cardiac surgery using this … articles and 4 reviews that evaluated the effectiveness of subglottic secretion aspiration in reducing the occurrence

114. PS Grantee | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/index.html?page=12
     January 01, 2024 - HS 13914 Topic(s): Diagnostic Safety Publication Date: March 2011 Verbal Order Policies, Occurrence

115. Tool: Task Assistance | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps-program/curriculum/mutual/tools/task.html
     May 01, 2023 - a climate in which it is expected that assistance will be actively sought and offered to reduce the occurrence

116. Final Progress Report: Older adult safety while receiving home health services after hospital discharge (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/arbaje-report.pdf
     January 01, 2024 - identified in SA1 on (1) its importance to ensuring safety during care transitions and (2) its frequency of occurrence … The researchers followed each patient for the occurrence of an ED visit or hospitalization within 30 … During feasibility testing, descriptive analyses were conducted to assess the occurrence of safety threats … also observed and rated each transition at the end of the visit and followed each patient for the occurrence … Occurrence of transition safety issues as measured by index items: The vast majority of transitions

117. Final Progress Report: Cancer Patient Safety Learning Laboratory (CaPSLL): Preventing Clinical Deterioration in Outpatients (pdf file)
     www.ahrq.gov/sites/default/files/2024-10/weinger-france-report.pdf
     January 01, 2024 - predictive model of deterioration, using ensemble machine learning methods to predict the possible occurrence … co-investigators) regularly reviewed the reported NREs for confirmation subsequently identified the occurrence … with G-Tube (n=4 occurrences), chemotherapy reactions (anaphylaxis, angina; n=2 occurrences), and one occurrence

118. Final Progress Report: Unexpected Clinical Events: Impact on Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-12/weinger2-report.pdf
     January 01, 2024 - In an interim analysis conducted a year ago, the relationship between antecedent variables and NRE occurrence … questionnaire at the end of 50 clinical cases regarding their intraoperative reading practices and the occurrence … to identify and analyze NRE, built a large archive of anesthesia NRE, elucidated the role in the occurrence … Future work must evaluate whether NRE occurrence and severity are valid and reliable process variables … Future research must determine if NRE occurrence is associated with a higher incidence of patient injury

119. Regulation of Health Policy: Patient Safety and the States (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Weinberg.pdf
     March 01, 2004 - Nevada defines a sentinel event as “an unexpected occurrence” involving death or serious injury or the … that notification to the patient, or to an adult family member, must be made within 7 days of the occurrence … or discovery of the occurrence of the serious event.) … JCAHO has adopted standardized definitions: a sentinel event is “an unexpected occurrence involving … NYPORTS, the New York Patient Occurrence Reporting and Tracking System, Annual Report 2000–2001.

120. Advancing Patient-Centered Care for People Living With Multiple Chronic Conditions | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/multichronic/mcc.html
     May 01, 2025 - Defining Multiple Chronic Conditions: In its work, AHRQ defines MCC as the co-occurrence of two or more