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Showing results for "occurring".

161. 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. …

162. 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.

163. Surge in Drug Shortages Occurred in Wake of Pandemic, Study Finds | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsletters/e-newsletter/908.html
     April 01, 2024 - Surge in Drug Shortages Occurred in Wake of Pandemic, Study Finds Issue Number 908 AHRQ News Now is a weekly newsletter that highlights agency research and program activities. April 9, 2024 AHRQ Stats: Trends in Psychological Distress During the COVID-19 Pandemic Between 2018 and 2021, the proportion …

164. 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

165. 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. …

166. 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

167. 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

168. 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 - A delay was an interruption occurring at a time when the nurse was not involved in a nursing process … A direct care disruption was an interruption occurring when a direct care activity (e.g., medication

169. 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…

170. Understand the Science of Safety for Perinatal Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-facilitator-guide.pdf
     May 01, 2017 - their ability to learn from mistakes and implement procedures to help prevent serious errors from occurring

171. Quantitative and Qualitative Analysis of Medication Errors: The New York Experience (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Duthie.pdf
     January 01, 2004 - Analysis of the data by type of occurrence (Figure 2) identified the most commonly occurring error as

172. Learning From Defects Through Sensemaking: Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-fac-notes.html
     December 01, 2017 - What led to the next factor that contributed to the defect occurring?

173. AHRQ Tribal Consultation Policy | Agency for Healthcare Research and Quality
     www.ahrq.gov/cpi/about/mission/strategic-plan/tribal-consultation-policy.html
     August 01, 2014 - Regularly Occurring Consultation AHRQ will take advantage of national meetings sponsored by different

174. Facilitator Guide: Learning From Defects Through Sensemaking (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects_facnotes.docx
     December 01, 2017 - What led to the next factor that contributed to the defect occurring?

175. Final Progress Report: Adverse Event-Directed Analysis in Ambulatory Primary Care (pdf file)
     www.ahrq.gov/sites/default/files/2024-10/kennerly-ballard-report.pdf
     January 01, 2024 - IOM) report “To Err Is Human” illuminated the high rate of medical errors and adverse events (AEs) occurring … information about AEs to achieve as complete an understanding as possible of both the types of events occurring … leadership necessary to implement changes, financial feasibility, and consideration of other initiatives occurring … the tool (BI-OTT3 and BI-OTT4) and to use the tool to review patient charts to collect data on AEs occurring … Analysis of the physician confirmatory reviews for visits occurring during CY2006 revealed good inter-rater

176. Final Progress Report: The Role of Collective Mindfulness in Delivering Reliable and Safe Perioperative Care to Neonates (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/france-report.pdf
     January 01, 2024 - Determine the effects of perceived CM on the incidence and severity of NREs occurring during and across … perceived CM; Aim 2, to determine the impact of perceived CM on the incidence (count) and severity of NREs occurring … Aim 2 – Determine the impact of perceived CM on the incidence and severity of NREs occurring during … these phases of care.26,90 NRE counts are reported as an integer count of the total number of NREs occurring … Aim 2 – Determine the impact of perceived CM on the incidence and severity of NREs occurring during and

177. Equipment and Supplies | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/shuttered/toolkitchecklist/surgetkit3.html
     July 01, 2018 - Equipment and Supplies Public Health Emergency Preparedness 1. Preplanning Description: The equipment and supplies team must lay the groundwork for procurement prior to a surge event. Key decisions include: determining whether to outsource staffing and procurement of the equipment and supplies, deciding wh…

178. Learning From Defects Through Sensemaking: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-slides.html
     December 01, 2017 - Learning From Defects Through Sensemaking: Slide Presentation AHRQ Safety Program for Surgery Slide 1: AHRQ Safety Program for Surgery—Implementation Learning From Defects through Sensemaking Slide 2: Learning Objectives Describe difference between first-order and second-order problem-solving. L…

179. Applicants Sought for National Coordinating Center and National Evaluation Center for State-Based Healthcare Extension Service | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsletters/e-newsletter/931.html
     October 01, 2024 - division director in AHRQ’s Center for Quality Improvement and Patient Safety—assert that progress is occurring

180. Implementation Planning | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps-program/curriculum/implement/activity/plan.html
     February 01, 2024 - Implementation Planning If your organization decides that implementing part or all of the TeamSTEPPS curriculum would be of value, carefully think through how to implement and sustain what you intend to teach. Successful and sustainable implementation begins with effective implementation planning. Basis of Im…