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Showing results for "occurrence".

  1. Chapter 2. ST-PRA Development | Agency for Healthcare Research and Quality

    www.ahrq.gov/research/findings/final-reports/stpra/stpra2.html
    April 01, 2018 - prioritization of risk reduction interventions based on sequences that have the highest probability of occurrence … element of the ST-PRA models: A review and comparison of policies and procedures related to the occurrence … Using these inputs enabled us to identify the multiple connections associated with the occurrence of … This process leads to a probability of occurrence of the top-level event, along with the major risk points … Cut sets are a unique combination of events leading to the occurrence of a top level event (an SSI).

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72672/psn-pdf
    January 27, 2021 - that a smart phone app providing just-in-time medication administration information could reduce the occurrence

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60359/psn-pdf
    May 20, 2020 - libraries when programing pumps and assessed equipment competency as actions to mitigate similar incident occurrence

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837000/psn-pdf
    May 06, 2022 - lessons-learned-about-human-fallibility-system-design-and-justice-aftermath- fatal-medication Organizational factors can contribute to the occurrence

  5. Adverse Events Among In-Hospital Medicare Patients in 2021 and 2022 (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/quality-measures/qsrs/qsrs-2021-2023-adverse-event-data-report.pdf
    January 01, 2023 - Among the four cohorts, the CRITICAL ACCESS cohort had the lowest occurrence of AEs (3.4%). … Among the four cohorts, the CRITICAL ACCESS cohort had the lowest occurrence of AEs (3.2%). … Among the four cohorts, the CRITICAL ACCESS cohort had the lowest occurrence of AEs (2.3%). … The CRITICAL ACCESS cohort had the lowest occurrence of AEs in each of the 3 years. … Estimating the Occurrence of Adverse Events in Medicare Hospital Stays D.

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36860/psn-pdf
    January 20, 2016 - paper describes a tool that employs triggers to identify adverse events and measure their rate of occurrence

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41510/psn-pdf
    July 11, 2012 - us-inaction-lets-look-alike-tubes-kill-patients https://psnet.ahrq.gov/issue/tubing-misconnections-persistent-and-potentially-deadly-occurrence

  8. Final Research Plan: Folic Acid Supplementation to Prevent Neural Tube Defects: Preventive Medication | United States Preventive Services Taskforce

    www.uspreventiveservicestaskforce.org/uspstf/document/final-research-plan/folic-acid-for-the-prevention-of-neural-tube-defects-preventive-medication
    October 21, 2021 - To what extent does folic acid supplementation reduce the risk for neural tube defects (NTDs) (first occurrence … Does the effect of folic acid supplementation on NTDs (first occurrence) differ by race and ethnicity

  9. The challenges in monitoring and preventing patient safety incidents for people with intellectual disabilities in NHS acute hospitals: evidence from a mixed-methods study. | PSNet

    psnet.ahrq.gov/issue/challenges-monitoring-and-preventing-patient-safety-incidents-people-intellectual
    May 20, 2020 - RIS Download Citation Related Resources From the Same Author(s) Occurrence … November 13, 2013 The relationship between the nursing work environment and the occurrence

  10. Weekend effect on in-hospital mortality for ischemic and hemorrhagic stroke in US rural and urban hospitals. | PSNet

    psnet.ahrq.gov/issue/weekend-effect-hospital-mortality-ischemic-and-hemorrhagic-stroke-us-rural-and-urban
    January 19, 2022 - June 15, 2022 Occurrence of no-harm incidents and adverse events in hospitalized patients … August 17, 2022 Occurrence of no-harm incidents and adverse events in hospitalized patients

  11. Pakyz, Amy | Agency for Healthcare Research and Quality

    www.ahrq.gov/funding/training-grants/grants/active/kawards/Kawdsumpaky.html
    October 01, 2014 - patterns, infection prevention and control, and pharmacy policies predict C. difficile infection (CDI) occurrence

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/860732/psn-pdf
    April 16, 2024 - serious-incident Retained surgical items are never events that continue to occur despite efforts to reduce their occurrence

  13. Appendix A. Literature Review | Agency for Healthcare Research and Quality

    www.ahrq.gov/research/findings/final-reports/stpra/stpraapa.html
    April 01, 2018 - surgical wound class, identification of positive intraoperative wound cultures, duration of surgery, occurrence … Factors associated with the occurrence of positive intraoperative cultures: surgical wound class (35% … Confirmed an association between the duration of the surgical procedure and the occurrence of infection … finding of our study was that the CD4+ cell count and the HIV viral load were not associated to SSI occurrence … There was a direct association between the occurrence of wound infections and high ASA classification

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42202/psn-pdf
    May 01, 2013 - economic-measurement-medical-errors-using-hospital-claims-database https://psnet.ahrq.gov/issue/relationship-between-occurrence-surgical-complications-and-hospital-finances

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36051/psn-pdf
    January 05, 2017 - using-health-care-failure-mode-and-effect-analysis-va-national-center-patient-safetys https://psnet.ahrq.gov/issue/tubing-misconnections-persistent-and-potentially-deadly-occurrence

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867690/psn-pdf
    March 05, 2025 - Data from four studies that included 19-20 hospitals were analyzed to estimate the occurrence of diagnostic

  17. Latent Error (or Latent Condition) | PSNet

    psnet.ahrq.gov/glossary/latent-error-or-latent-condition
    September 13, 2021 - latent conditions) refer to less apparent failures of organization or design that contributed to the occurrence

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72590/psn-pdf
    December 23, 2020 - effects-night-surgery-postoperative-mortality-and-morbidity-multicentre-cohort-study https://psnet.ahrq.gov/issue/association-between-night-time-surgery-and-occurrence-intraoperative-adverse-events-and

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848378/psn-pdf
    May 04, 2023 - safely-practicing-new-environment-qualitative-study-inform-physician-onboarding-practices https://psnet.ahrq.gov/issue/physician-mentorship-associated-occurrence-adverse-patient-safety-events

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72482/psn-pdf
    November 18, 2020 - reality Debriefing is an established strategy teams use to learn from critical events, reduce event occurrence
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