Results

Total Results: 2,790 records

Showing results for "occurs".

281. Standardizing Medication Error Event Reporting in the U.S. Department of Defense (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Nosek.pdf
     March 01, 2004 - Standardizing Medication Error Event Reporting in the U.S. Department of Defense 361 Standardizing Medication Error Event Reporting in the U.S. Department of Defense Ronald A. Nosek, Jr., Judy McMeekin, Geoffrey W. Rake Abstract Soon after the 1999 Institute of Medicine report, To Err Is Human, was released, …

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

283. Morningbriefing (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/morningbriefing.doc
     June 02, 2025 - Conducting a Morning Briefing Problem statement: Physicians can improve communication with nursing staff while more efficiently prioritizing patient care delivery and admissions and discharges. What is a Morning Briefing? A morning briefing is a dialogue between two or more people using concise and relevant informati…

284. Module 3: Script and Slides (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/problem-solving/problem-solving-facnotes.docx
     May 01, 2017 - If an event occurs during care provision that a staff member is concerned about, this simple protocol

285. Module 3: Problem Solving and Escalation - Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/management/problem-solving-fac-notes.html
     June 01, 2017 - If an event occurs during care provision that a staff member is concerned about, this simple protocol

286. Development and Validation of the Medication Administration Error Reporting Survey (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Wakefield2.pdf
     January 01, 2003 - What should a pharmacy manager do when a serious medication error occurs? A panel discussion.

287. Candor-Impguide (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/candor-impguide.pdf
     April 01, 2016 - After the event is identified as a CANDOR event, CANDOR System Activation occurs and triggers the start … While an initial disclosure conversation will occur within 60 minutes after the CANDOR event occurs, … CANDOR Implementation Phases CANDOR process implementation occurs in three phases, and the toolkit provides

288. Risk-Based Patient Safety Metrics (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Scanlon_62.pdf
     March 25, 2008 - order for chart review to identify all errors, the following sequence of events must occur: Error occurs … numerator of error rates through direct observation is contingent on another sequence of events: Error occurs … those in power are likely to blame the clinician on the “sharp end” when patient harm or an error occurs … , identification, measurement, and analysis of injuries are reactive, taking place after an injury occurs

289. Readmissions for Selected Infections Due to Medical Care: Expanding the Definition of a Patient Safety Indicator (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Gallagher2.pdf
     January 01, 2016 - This occurs when a patient has a primary and secondary diagnosis code for selected infections due to … This occurs when a patient has a secondary code for Selected Infections Due to Medical Care that meets

290. Conducting a Morning Briefing | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/toolkit/morning-briefing.html
     December 01, 2012 - Conducting a Morning Briefing CUSP Toolkit Improve communication with nursing staff Problem statement: Physicians can improve communication with nursing staff while more efficiently prioritizing patient care delivery and admissions and discharges. What is a Morning Briefing? A morning briefing is a dial…

291. Selected Best Practices and Suggestions for Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4k_combo_psi14-dehiscence-bestpractices.pdf
     May 20, 2016 - • Postoperative wound dehiscence occurs in up to 3% of abdominal surgeries, and is associated with significant

292. Accessible Facilitator Guide: Learn From Defects for Sustainability (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_learn_from_defects_facnotes.docx
     December 01, 2017 - Consider its impact on causing the defect, and whether the factor occurs rarely or has a likelihood of … For example, the green “x” represents a contributing factor that occurs often and is a major reason why

293. Sustainability: Learning From Defects: Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/surgery/modules/sustainability/learn-from-defects-fac-notes.html
     December 01, 2017 - Consider its impact on causing the defect, and whether the factor occurs rarely or has a likelihood of … For example, the green “x” represents a contributing factor that occurs often and is a major reason why

294. A Visual Computer Interface Concept for Making Error Reporting Useful at the Point of Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Singh_69.pdf
     April 04, 2008 - /her own domain (i.e., home/community) and recognizes that this is where most health care actually occurs

295. AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/factraining.html
     December 01, 2014 - It also asks which staff members are invited, who leads the meeting, and how often it occurs. … Investigate root causes when an adverse event occurs. … section on root cause analysis to understand what investigation takes place after an adverse event occurs

296. Final Progress Report: Developing Definitions, Measurement Strategies, and Links to Medication Errors (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/savage-report.pdf
     January 01, 2024 - This study highlights when this rework occurs, why it occurs, and, as we will elaborate below, how rework … [probe to clarify problems/solutions] For each problem/solution, ask how frequently it occurs. 2.

297. Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department (pdf file)
     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

298. Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department (pdf file)
     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

299. Improving the Safety of Heparin Administration by Implementing a Human Factors Process Analysis (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Harder.pdf
     May 19, 2003 - Improving the Safety of Heparin Administration by Implementing a Human Factors Process Analysis 323 Improving the Safety of Heparin Administration by Implementing a Human Factors Process Analysis Kathleen A. Harder, John R. Bloomfield, Sue E. Sendelbach, Michele F. Shepherd, Pam S. Rush, Jamie S. Sinclair,…

300. Final Progress Report: Crossing an Invisible Quality Chasm: From NICU to Ambulatory Care (pdf file)
     www.ahrq.gov/sites/default/files/2024-12/moyer-report.pdf
     January 01, 2024 - Follow-up appointment occurs A) Patient is seen by primary care pediatrician B) Primary care pediatrician