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Total Results: 2,792 records

Showing results for "occurring".

141. Pocket Cards_4 Moments (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/four-moments/poster-three-options.pdf
     November 01, 2019 - Pocket Cards_4 Moments Th e Fo ur M om en ts o f A nt ib io tic D ec isi on M ak in g AHRQ Pub. No. 17(20)-0028-EF November 2019 Moment 1 occurs at the time that initiation of antibiotic therapy is being considered. Ask, “Does my patient have an infection that requires antibiotics?” Mome…

142. Exhibit 3.5. Chronology of Quality Improvement and Lean at the Parent Organization and Academic Medical Center | Agency for Healthcare Research and Quality
     www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit3-5.html
     November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies Exhibit 3.5. Chronology of Quality Improvement and Lean at the Parent Organization and Academic Medical Center Previous Page Next Page Table of Contents Improving Care Delivery Through Lean: Implementation Case Studies Introduction …

143. Using Probabilistic Risk Assessment to Model Medication System Failures in Long-term Care Facilities (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Comden.pdf
     January 01, 2003 - and lacks the detail necessary to design systems interventions to reduce the risk of serious errors occurring … variation is included in the models because it could raise or lower the cumulative risk of an error occurring … establish the behavioral and systems context that either increases or decreases the probability of errors occurring

144. Scisafetynotes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/understand/scisafetynotes.docx
     June 02, 2025 - increase their ability to learn from mistakes and implement procedures to help prevent serious errors from occurring

145. Understand the Science of Safety for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/understand-sci-fac-guide.html
     July 01, 2023 - increase their ability to learn from mistakes and implement procedures to help prevent serious errors from occurring

146. An Overview of the CANDOR Process
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4/module4-event-reporting-investigation-analysis.pptx
     September 10, 2015 - best practice of creating a hotline for staff to call when they feel a CANDOR event has occurred or is occurring

147. Sensemaking and Learn From Defects for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-fac-guide.html
     July 01, 2023 - CUSP and Sensemaking tools help teams identify defects and identify ways to prevent them from occurring

148. Practice Self-Assessment Tool for Opioid Use in Older Adults (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/opioids/compendium/opioids-compendium-self-assessment.pdf
     December 01, 2023 - Practice Self-Assessment Tool for Opioid Use in Older Adults www.ahrq.gov Practice Self-Assessment Tool for Opioid Use in Older Adults Instructions: This quality improvement self-assessment tool is best completed in a group discussion with all staff involved in this work. It can also be completed by staff indi…

149. Final Progress Report: Pediatric Medication Safety: Analyses from the MEDMARX Medication Error Reporting System (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/bundy-report.pdf
     January 01, 2024 - likely to result in harmful medication errors included use of ISMP High- Alert Medications, errors occurring … harmful errors involved significantly more administering errors (59% vs. 32%, p = 0.023), errors occurring

150. 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 - best practice of creating a hotline for staff to call when they feel a CANDOR event has occurred or is occurring

151. Understand-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-facilitator-guide.docx
     May 01, 2017 - increase their ability to learn from mistakes and implement procedures to help prevent serious errors from occurring

152. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/ontime-preventablehospitaledvisits-overview.pptx
     May 01, 2017 - facility level for residents at high risk for adverse events Are generated weekly Can show trends occurring

153. Do Transient Working Conditions Trigger Medical Errors? (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Grayson.pdf
     January 01, 2003 - and reported increased distractions and feelings of fatigue during the 30 minutes prior to the error occurring

154. 023-Ss-Cusp-Learning-From-Defects-Fg (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/023-ss-cusp-learning-from-defects-fg.docx
     April 01, 2025 - A factor that is not a major reason but commonly occurring may be low-hanging fruit and easier to tackle

155. Learn-From-Defects-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.docx
     May 01, 2017 - CUSP and Sensemaking tools help teams identify defects and identify ways to prevent them from occurring

156. NICU Family Information Packet, Appendix B, Patent Ductus Arteriosus (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-pda.pdf
     June 02, 2025 - NICU Family Information Packet, Appendix B, Patent Ductus Arteriosus Patent Ductus Arteriosus Characteristics ■ A persistent open connection beyond 3 months of age between the pulmonary artery and the aorta with blood flow from the aorta to the pulmonary artery. ■ An open ductus may lead to: – Congestive heart…

157. Four Moments Poster (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/four-moments/poster-one-option.pdf
     November 01, 2019 - Four Moments Poster AHRQ Pub. No. 17(20)-0028-EF November 2019 Moment 1 occurs at the time initiation of antibiotic therapy is considered: Ask, “Does my patient have an infection that requires antibiotics?” occurs when the dec…

158. Accessible Facilitator Guide: Learn From Defects for Sustainability (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_learn_from_defects_facnotes.docx
     December 01, 2017 - Ask them why these problems are occurring and where the problems reside. … Consider its impact on causing the defect, and whether the factor occurs rarely or has a likelihood of occurring

159. Sustainability: Learning From Defects: Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/surgery/modules/sustainability/learn-from-defects-fac-notes.html
     December 01, 2017 - Ask them why these problems are occurring and where the problems reside. … Consider its impact on causing the defect, and whether the factor occurs rarely or has a likelihood of occurring

160. Sensemaking and Learn from Defects for Perinatal Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.pdf
     May 01, 2017 - • CUSP and Sensemaking tools help teams identify defects and identify ways to prevent them from occurring