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Total Results: 4,281 records

Showing results for "occurring".

261. 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?

262. 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?

263. Executive Summary | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/demo-program/grants/summary.html
     August 01, 2022 - The baseline rates were generally very low, with most CSAE improvements occurring in favoring intervention … For births occurring from 2001-2012, the project reported a 19% reduction in frequency of obstetric claims

264. 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

265. 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…

266. 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.

267. 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

268. 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

269. 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…

270. Quick Reference Guide to TeamSTEPPS Action Planning | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps/instructor/reference/quickrefguide.html
     March 01, 2014 - Quick Reference Guide to TeamSTEPPS Action Planning Step 1: Create a Change Team Objective: To create a team of leaders and staff members with the authority, expertise, credibility, and motivation necessary to drive a successful TeamSTEPPS Initiative . Ensure key leadership representation: senior leadership…

271. 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

272. TeamSTEPPS for Office-Based Care Implementation Workbook (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/officebasedcare/impworkbook.pdf
     December 11, 2015 - TeamSTEPPS for Office-Based Care Implementation Workbook TeamSTEPPS for Office-Based Care Implementation Workbook TeamSTEPPS® for Office-Based Care TeamSTEPPS Action Planning At-A-Glance 1 2 3 4 5 6 7 8 9 10 Create a Change Team Define the Problem, Challenge, or Opportunity for Impro…

273. Health Care Simulation to Advance Safety: AHRQ Issue Brief (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/simulation-brief.pdf
     February 01, 2015 - Simulation The simulation community has witnessed tremendous growth and energy in the past 15 years, occurring … should concerns relating to variable patient acuity, complexity of operations, and less frequently occurring

274. Health Care Simulation to Advance Safety: AHRQ Issue Brief (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/factsheets/errors-safety/simulproj15/simulation-brief.pdf
     February 01, 2015 - Simulation The simulation community has witnessed tremendous growth and energy in the past 15 years, occurring … should concerns relating to variable patient acuity, complexity of operations, and less frequently occurring

275. CANDOR Helped Significantly Reduce Patient Safety Events, Malpractice Claims at MedStar Health | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/201712.html
     September 01, 2017 - CANDOR Helped Significantly Reduce Patient Safety Events, Malpractice Claims at MedStar Health Search All Impact Case Studies September 2017 MedStar Health, a large health system in the Baltimore, MD/Washington, DC, metropolitan area, reduced serious patient safety events by about 65 percent and reduced the…

276. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/officebasedcare/module6/6-ts-office-support.pptx
     January 20, 2006 - feedback is: Timely Respectful Specific Directed toward improvement Helps prevent the same problem from occurring

277. Screening in Neonatal Intensive Care Unit Reduced Staph Infection Rate by 43 Percent | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsletters/e-newsletter/640.html
     November 01, 2018 - AHRQ’s strategies to improve quality, safety and value are occurring while numerous technological innovations

278. TeamSTEPPS 2.0 Quick Reference Guide to TeamSTEPPS Action Planning (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/reference/quickrefguide.pdf
     March 13, 2014 - TeamSTEPPS 2.0 Quick Reference Guide to TeamSTEPPS Action Planning TeamSTEPPS 2.0 Guide to Action Quick Reference - 1 The Quick Reference Guide to TeamSTEPPS Action Planning Step 1: Create a Change Team Objective: To create a team of leaders and staff members with the authority, expertise, credibility, …

279. Saving Lives and Saving Money: Hospital-Acquired Conditions Update | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/2014-final.html
     January 01, 2018 - from 2011 to 2014 as a result of the reduction in HACs, with nearly $16 billion of those cost savings occurring

280. Final Progress Report: Ambulatory Patient Safety of Clients in Treatment for Substance Abuse (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/mcfarland-report.pdf
     January 01, 2025 - For example, there is evidence suggesting that prescription medication errors presumably occurring among … Clients at this clinic have numerous problems associated with chemical dependency and co-occurring mental … charts, heavy workloads and limited time for charting may enhance the likelihood of such an error occurring … Classes of patients (e.g., co-occurring disorders, DUI, self-referred, gamblers, Byrne grant).