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Total Results: 2,959 records

Showing results for "occurring".

161. 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

162. 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

163. 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

164. 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

165. 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

166. 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

167. 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…

168. 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…

169. Appendix G. Safety and Adverse Events | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/universal-icu-decolonization/universal-icu-apg.html
     September 01, 2013 - Universal ICU Decolonization: An Enhanced Protocol Appendix G. Safety and Adverse Events Previous Page   Table of Contents Universal ICU Decolonization: An Enhanced Protocol Introduction and Welcome Universal ICU Decolonization Protocol Overview Scientific Rationale References Appendix A. …

170. 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

171. 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

172. 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

173. Appendix G. Safety and Adverse Events | Agency for Healthcare Research and Quality
     www.ahrq.gov/es/hai/universal-icu-decolonization/universal-icu-apg.html
     September 01, 2013 - Universal ICU Decolonization: An Enhanced Protocol Appendix G. Safety and Adverse Events Previous Page   Table of Contents Universal ICU Decolonization: An Enhanced Protocol Introduction and Welcome Universal ICU Decolonization Protocol Overview Scientific Rationale References Appendix A. …

174. 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013 | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/hacrate2013.html
     January 01, 2018 - incidents of harm occurred in 2011, 2012, and 2013 (compared to 2010), with most of the improvement occurring

175. Efforts To Improve Patient Safety Result in 1.3 Million Fewer Patient Harms | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/interimhacrate2013.html
     November 01, 2015 - incidents of harm occurred in 2011, 2012, and 2013 (compared to 2010), with most of the improvement occurring

176. Mixed Methods Analysis of Medical Error Event Reports: A Report from the ASIPS Collaborative (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Harris.pdf
     June 30, 2004 - develop codes particular to the analysis of specific kinds of reported events and to transform commonly occurring … in this fashion suggested potential intervention strategies for reducing the likelihood of an error occurring … or of an occurring error cascading into patient harm.

177. Identify Defects Through Sensemaking, Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/modules/identify/notes.html
     December 01, 2012 - Ask: What does the nurse suggest that the team do to reduce the likelihood of the defect occurring … CUSP and Sensemaking tools help teams identify defects and identify ways to prevent them from occurring

178. Four Moments of Antibiotic Decision Making Explained (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/four-moments-explained.pdf
     June 01, 2021 - Four Moments of Antibiotic Decision Making Explained Moment 1 occurs when a resident is assessed for a change in status and there is a concern for infection. Sometimes long-term care staff recognize that something is not quite right with the resident but aren’t clear on what is wrong. The person doing the assessmen…

179. 004-Cusp-Learning-From-Defects (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/004-cusp-learning-from-defects.docx
     October 01, 2024 - A factor that is not a major reason but commonly occurring may be low hanging fruit and easier to tackle

180. Final Progress Report: Patient Safety in Hospice Care (pdf file)
     www.ahrq.gov/sites/default/files/2024-10/smucker-report.pdf
     January 01, 2024 - designations have led to incentives to identify best practices and policies to prevent “never events” from occurring