Results

Total Results: 2,790 records

Showing results for "occurs".

261. 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. …

262. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/fallpxoverview.pptx
     October 01, 2017 - Investigate the root cause when an adverse event occurs.

263. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-factraining-slides.pptx
     November 01, 2016 - Investigate the root cause when an adverse event occurs.

264. Final Progress Report: Creating Learning Cultures Around Mistakes for Residents (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/hoff-report.pdf
     January 01, 2024 - important point in a physician’s career to ingrain a knowledge and use of learning-oriented practices occurs … offered less-than-ideal opportunities for real- time (i.e., at the moment the mistake or near miss occurs

265. 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 - accidental breach in protocol will be caught by a check or team alert when the break in policy or procedure occurs

266. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/ontime-preventablehospitaledvisits-overview.pptx
     May 01, 2017 - Investigate the root cause when an adverse event occurs.

267. Pediatric Health Care Quality Measures: Considerations for Pharmacotherapy (pdf file)
     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

268. Clinical Topic (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/0085textdescription.pdf
     January 01, 2012 - ) Definition: The group of patients in the denominator for whom a process or outcome of care occurs

269. Section 4. Identifying Strategies | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/ptflow/section4.html
     July 01, 2018 - Bottom-up selection often occurs at hospitals that use performance improvement methodologies, such as

270. In Situ Simulation: Challenges and Results (pdf file)
     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.

271. PowerPoint Presentation: Learn From Defects Through Sensemaking
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects.pptx
     December 01, 2017 - The problem occurs when we recoil from cognitive tools, like checklists, because we ARE good at our jobs … ideal target for developing an intervention is a factor that is a major contributor to the defect and occurs … If there is something that occurs rarely but has a singular impact on this particular defect, consider … If the factor is a minor contributor to the defect, but occurs often, then consider intervening on this

272. An Overview of the CANDOR Process
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module8/module8-organizational-learning-sustainability.pptx
     August 20, 2015 - events. 3 Kotter’s 8 Steps of Change Model2 Module 8 4 As seen in TeamSTEPPS® Sustainability occurs … Formal Programs to Prepare People To Learn and Apply New Skills Module 8 5 Sustainability occurs

273. Chapter 2. Analyze Care Delivery | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/vtguide/guide2.html
     February 01, 2016 - of Failure As a starting point in its analysis, the team should estimate how reliably each step occurs

274. Chapter 2. Analyze Care Delivery | Agency for Healthcare Research and Quality
     www.ahrq.gov/es/patient-safety/settings/hospital/vtguide/guide2.html
     February 01, 2016 - of Failure As a starting point in its analysis, the team should estimate how reliably each step occurs

275. Best Practices in the Management of Patients With Antibiotic Allergies – Facilitator Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/allergies-guide.docx
     September 01, 2022 - Another cause of incorrect penicillin allergy labels occurs when other family members report antibiotic

276. Identify Defects Through Sensemaking, Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/modules/identify/notes.html
     December 01, 2012 - A rule-based failure occurs when a person does not carry out a procedure or protocol correctly or chooses … relationship between defects and production pressures—leaving hazards unnoticed until a sentinel event occurs

277. Final Report: Using Risk Models To Improve Safety With Dispensing High-Alert Medications in Community Pharmacies (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/cohen-report.pdf
     January 01, 2024 - .39,40,41 RCA is typically a top-down, reactive process 2 used after a preventable adverse event occurs … or nearly occurs to provide insight into system and process failures; however, RCA does not examine … Unless patient counseling occurs at the point of sale, dispensing a prescription to the wrong patient … If patient counseling occurs (30%), the probability of noticing the error was estimated at 90%. … Assessing patient safety risk before the injury occurs: an introduction to socio-technical probabilistic

278. Final Progress Report: Patient Safety in Hospice Care (pdf file)
     www.ahrq.gov/sites/default/files/2024-10/smucker-report.pdf
     January 01, 2024 - Because most communication occurs by telephone or by fax between primary care physician offices, team

279. 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 …

280. 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 - • Establish intravenous access for rapid intervention if an adverse effect occurs.