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Total Results: 2,959 records

Showing results for "occurs".

301. 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

302. 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. …

303. 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

304. 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

305. 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013 | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/hacrate2013.html
     January 01, 2018 - Persistent support for research focused on understanding health care harm—why it occurs, what can be

306. Saving Lives and Saving Money: Hospital-Acquired Conditions Update | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/interimhacrate2014.html
     January 01, 2018 - Saving Lives and Saving Money: Hospital-Acquired Conditions Update Next Page Table of Contents Saving Lives and Saving Money: Hospital-Acquired Conditions Update Appendix: Incidence of Hospital-Acquired Conditions in the Partnership for Patients: Estimates and Projected and Measured Impact …

307. 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

308. Efforts To Improve Patient Safety Result in 1.3 Million Fewer Patient Harms | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/interimhacrate2013.html
     November 01, 2015 - Persistent support for research focused on understanding health care harm—why it occurs, what can be

309. 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

310. 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.

311. 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

312. 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

313. 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

314. 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 …

315. Tool 1: Readmission Data Analysis and Interpretation (xls file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/mcaidread_tool1_data_analysis_final.xlsx
     June 02, 2025 - Topic 5: Days Between Discharge and Readmission What percentage of readmissions occurs within 4 days … What percentage of readmissions occurs within 4 days of discharge? Within 10 days?

316. 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

317. 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

318. 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

319. 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.

320. Proactive Risk Assessment of Surgical Site Infections in Ambulatory Surgery Centers (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/stpra/stpra.pdf
     March 01, 2012 - This occurs not only because the rates of known risks may be increased, but also because additional, … or infection rates, because the treatment for these 12 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 … connected to the OR gate occurs). … For example, assuming that the top event SSI occurs, the criticality of basic event A is the probability