-
www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module5-situation-monitoring.pptx
January 10, 2022 - teams to take steps to interrupt or correct an action or event before harm or injury to the patient occurs … error
An opportunity to interrupt or correct an action or event before harm or injury to the patient occurs
-
www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/situ/simulation-antepart-hemorrhage.html
July 01, 2023 - Trigger #3
Large gush of blood occurs.
… Trigger #3
Large gush of blood occurs.
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospital/sops-hsops-2-translation-guidelines.pdf
August 01, 2023 - • More about this item: The difference between this item and D1 is that the mistake occurs in
D2 – it … Although the mistake actually occurs, there is no harm to the
patient, but there could have been harm
-
www.ahrq.gov/sites/default/files/2024-01/higginson-report.pdf
January 01, 2024 - This practice is generally forbidden in most policies and
procedures, but this study found that it occurs … and fails
Q:0.28
Event593
Read back does not occur
Q:0.2
Gate483
Read back occurs and fails
Q … and fails
Q:0.28
Event593
Read back does not occur
Q:0.2
Gate483
Read back occurs and fails
Q … This type of human error typically occurs during routine tasks. … It occurs in part because the discontinuation process does not have the
controls that one sees in the
-
www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/resources/tools/reduce/antibiotic-faqs.html
July 01, 2017 - yeast ( Candida ) to enter the bladder, but whether or not a symptomatic infection with tissue damage occurs
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/resources/tools/reduce/antibiotic-faqs.docx
March 01, 2017 - yeast (Candida) to enter the bladder, but whether or not a symptomatic infection with tissue damage occurs
-
www.ahrq.gov/cpi/about/mission/strategic-plan/tribal-consultation-policy.html
August 01, 2014 - An integral element of this government-to-government relationship is that consultation occurs with federally-recognized … Tribal Consultation
Consultation occurs when the AHRQ Director/Deputy Director or their designee, and
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/036-sources-pathways-mrsa-one-pager.docx
October 01, 2024 - carriage is common in healthcare settings, affecting 7 percent of inpatients upon admission.8
· Infection occurs
-
www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-ai-wave4.html
July 01, 2025 - To understand how this distortion occurs, we can return to the toddler playing with the shape sorter
-
www.ahrq.gov/research/findings/final-reports/stpra/stpra2.html
April 01, 2018 - complication or infection rates, because the treatment for these complications and infections often occurs … The two major types of gates are "AND" gates (i.e., the output event occurs if all input events connected … to the AND gate occur) and "OR" gates (i.e., the output event occurs if at least one of the input events … connected to the OR gate occurs).
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/023-ss-cusp-learning-from-defects-fg.docx
April 01, 2025 - A contributing factor that is a major reason and occurs commonly is a good target for intervention. … A factor that falls in the category of being a minor reason for the defect and rarely occurs may not
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/situ/simulation_antepart-hemorrhage.docx
May 01, 2017 - Trigger #3
Large gush of blood occurs. … Trigger #3
Large gush of blood occurs.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/resources/infotranshsops.pdf
September 01, 2009 - (More about this item: The difference between this item and D1 is that the mistake
occurs in D3 – it … Although the mistake actually occurs, there is no
harm to the patient, but there could have been harm
-
www.ahrq.gov/hai/cauti-tools/archived-webinars/ed-catheter-insertions-slides.html
December 01, 2017 - application
Moral agency
Drive to act
Environmental:
Context in which decision making occurs … non-maleficence
Slide 35
Putting systems in place
Environmental: Context in which decision making occurs
-
www.ahrq.gov/sops/international/hospital/translators.html
October 01, 2014 - ( More about this item: The difference between this item and D1 is that the mistake occurs in D3—it is … Although the mistake actually occurs, there is no harm to the patient, but there could have been harm
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/040-mrsa-surveillance-notes.docx
October 01, 2024 - people in both community settings and healthcare facilities, but most of the morbidity and mortality occurs … facilities must know the MRSA prevalence among their patient population and when and where transmission occurs
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/engaging-physicians.pdf
April 01, 2022 - • When an unprofessional incident occurs, identify a peer (e.g., attending to attending,
resident
-
www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/dataspotlight-anemia-dialysis.pdf
December 02, 2019 - for hemoglobin production only
when a patient’s hemoglobin level is below 10 g/dL.2
Anemia commonly occurs
-
www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions4.html
June 01, 2023 - The transmission of this information occurs during the OR-to-ICU handoff.
-
www.ahrq.gov/hai/tools/cauti-hospitals/toolkit-impl.html
October 01, 2020 - Catheter-Associated Urinary Tract Infections in Hospital Units: Implementation Guide)
When a CAUTI occurs