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www.ahrq.gov/news/newsletters/e-newsletter/939.html
November 01, 2024 - Her AHRQ-funded studies have explored the reasons nonprescription antibiotic use occurs, the prevalence
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www.ahrq.gov/hai/clabsi-tools/guide.html
January 01, 2020 - health care providers would never tolerate harming a patient intentionally, that is, in fact, what occurs … Use the Event Report Template and Nurse Letter
If a CLABSI occurs on your unit, your team should investigate
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www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/reporting-instructions-sw.pdf
March 31, 2017 - DARTNet
will be automatically notified when this occurs and we will pick and erase the file.
2
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d4i_pdi11-dehiscence-bestpractices.pdf
May 17, 2016 - • Postoperative wound dehiscence occurs in about 8 per 10,000 pediatric surgical discharges.1
• The
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d4g_pdi09-postoprespfailure-bestpractices.pdf
May 17, 2016 - surgery or
unplanned intubation/reintubation postoperatively.1
• Postoperative respiratory failure occurs
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4w_combo_pdi11-dehiscence-bestpractices.pdf
May 17, 2016 - • Postoperative wound dehiscence occurs in about 8 per 10,000 pediatric surgical discharges.1
• The
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4u_combo_pdi09-postoprespfailure-bestpractices.pdf
May 17, 2016 - surgery or
unplanned intubation/reintubation postoperatively.1
• Postoperative respiratory failure occurs
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0231-section-5-table-3.pdf
January 01, 2013 - Fluid
resuscitation should be stopped or
interrupted when no improvement of
tissue perfusion occurs
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www.ahrq.gov/news/newsletters/e-newsletter/915.html
June 01, 2024 - Mental health conditions, including perinatal or maternal depression that occurs during pregnancy and
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www.ahrq.gov/data/infographics/adverse-drug-events.html
August 01, 2018 - Adverse Drug Events Occurring in U.S. Hospitals
Adverse Drug Events Occurring in U.S. Hospitals (PDF, 1.5 MB)
Source: HCUP Statistical Brief #164: Characteristics of Adverse Drug Events Originating During the Hospital Stay, 2011
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www.ahrq.gov/sites/default/files/publications2/files/distributed-cognition-er-nurses_0.pdf
August 01, 2022 - The
decision making needed to make a diagnosis for a patient who presents to the ED occurs in a time … ED-based diagnostic error per year, with nearly half having the
potential for patient harm.6
Diagnosis occurs … In this view,
diagnosis is not the result of solitary thinking but rather a process that occurs through … While overlap in
patient interactions still occurs, the physician and nurse make a deliberate effort
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/distributed-cognition-er-nurses.pdf
August 01, 2022 - The
decision making needed to make a diagnosis for a patient who presents to the ED occurs in a time … ED-based diagnostic error per year, with nearly half having the
potential for patient harm.6
Diagnosis occurs … In this view,
diagnosis is not the result of solitary thinking but rather a process that occurs through … While overlap in
patient interactions still occurs, the physician and nurse make a deliberate effort
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www.ahrq.gov/hai/cauti-tools/cauti-icu/facil-guide/mod1.html
February 01, 2023 - discussion or questions from the learner:
How much training around aseptic insertion practices occurs … Potential points for discussion or questions from the learner:
How much nurse-physician communication occurs
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/antibiotic-patient-safety-facilitator-guide.docx
June 01, 2021 - However, the greatest risk occurs with clindamycin, third-generation cephalosporins, and fluoroquinolones … As a group, when a problem related to antibiotic prescribing occurs, ask—
What happened?
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/manage-resident-RTI-facilitator-guide.docx
June 01, 2021 - Aspiration Pneumonia Versus Pneumonitis
SAY:
Let’s differentiate aspiration pneumonitis and pneumonia that occurs … Aspiration pneumonitis occurs from inhaling gastric contents into the lungs, which in turn causes inflammation
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/LomotanDougherty2013.pdf
April 01, 2013 - Overuse occurs when a healthcare service is
provided under circumstances where harm is likely to
exceed … Misuse occurs when an appropriate service
has been selected but is applied incorrectly. … Less pediatric-focused research
occurs [12, 13], and the quality of pediatric-focused
research is lower
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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
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Patterson_48.pdf
May 05, 2008 - An alternative definition would define in situ simulation as, “Simulation that
1
occurs in the … Given that the
simulation occurs in the clinical environment, there are opportunities to identify hazards … In situ simulation occurs during the actual workday, utilizing on-duty clinical
providers, which alleviates … social anxiety is aggravated by
infrequent and unpredictable exposure to the stressful stimulus (as occurs … Sometimes
this occurs by design, but on other occasions, it might occur serendipitously.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/identify/sensemakingnotes.docx
June 02, 2025 - .
· A rule-based failure occurs when a person does not carry out a procedure or protocol correctly or … relationship between defects and production pressures—leaving hazards unnoticed until a sentinel event occurs
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www.ahrq.gov/research/shuttered/hospevac4.html
July 01, 2018 - As soon as possible after the event occurs, building integrity, critical infrastructure, and other environmental