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Showing results for "occurs".

  1. AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Under the Science of Safety

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-science-safety.pptx
    May 01, 2017 - many viewpoints as possible Alternate between convergent and divergent thinking7 Divergent thinking occurs … during brainstorming sessions and when trying to understand what might be occurring Convergent thinking occurs

  2. The Science of Improving Patient Safety

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/understand/scisafety.pptx
    March 01, 2009 - many viewpoints as possible Alternate between convergent and divergent thinking Divergent thinking occurs … brainstorming sessions, and when trying to understand what might be occurring10 Convergent thinking occurs

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47587/psn-pdf
    February 13, 2019 - and suggests that individual awareness of uncertainty is required to respond to the condition as it occurs

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37241/psn-pdf
    December 16, 2011 - organizations should avoid focusing on technical and organizational factors in isolation, as benefit occurs

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45350/psn-pdf
    October 21, 2016 - Large system failure occurs when such interventions are not disseminated and implemented.

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38255/psn-pdf
    December 03, 2008 - often examined by conducting case reviews or root cause analyses when an undesired patient outcome occurs

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45874/psn-pdf
    February 22, 2017 - The authors also explore the evidence on transparency in the ED when an error occurs and how to make

  8. Managing the adverse event occurring during elective, ambulatory pediatric surgery. | PSNet

    psnet.ahrq.gov/issue/managing-adverse-event-occurring-during-elective-ambulatory-pediatric-surgery
    March 01, 2023 - provides a framework of potential steps for health care professionals to take after a medical error occurs

  9. Assessing Progress on CLABSI and CAUTI Prevention | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/tools/clabsi-cauti-icu/assess/index.html
    April 01, 2022 - thoughtful statement (the Aim) that will guide the team in its actions and can be adjusted as change occurs

  10. Force-Field Analysis | Digital Healthcare Research

    digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/force-field-analysis
    January 01, 2023 - When these opposing forces are equal to each other, no change occurs.

  11. Understand the Science of Safety for Perinatal Safety | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/understand-sci-slides.html
    July 01, 2023 - Alternate between convergent and divergent thinking 7 Divergent thinking occurs during brainstorming … Convergent thinking occurs while formulating a treatment plan or focusing on a specific task.

  12. ‘Last responders’ seek to expand postmortem COVID testing In unexplained deaths. | PSNet

    psnet.ahrq.gov/issue/last-responders-seek-expand-postmortem-covid-testing-unexplained-deaths
    May 27, 2020 - Post-mortem examination is an important tool  for determining if misdiagnosis occurs.

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36291/psn-pdf
    October 25, 2010 - these data revealed that hospitals generally do not receive additional compensation when an error occurs

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43593/psn-pdf
    May 06, 2015 - reducing-risks-wrong-site-surgery-safety-practices-joint-commission-center- transforming Wrong-site surgery is a never event, but still occurs

  15. Module 1: Communication and Optimal Resolution (CANDOR) Toolkit Module 1: An Overview of the CANDOR Process

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/module1-overview.pptx
    June 02, 2025 - Module 1 5 When a CANDOR event occurs, the CANDOR process can be used to introduce a number of actions … Module 1 8 Now that we understand the definition of a CANDOR event, let’s briefly examine what occurs … After the CANDOR System Activation occurs, the 3rd and 4th components should occur simultaneously.

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36907/psn-pdf
    September 14, 2012 - When such an event occurs, many institutions mandate performance of a root cause analysis.

  17. Nursing Practice Guide (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/nursing-protocols/nursing-practice-guide.docx
    March 01, 2022 - .* CHG bath documentation occurs once per calendar day Provide staff educational huddles for central

  18. Nursing Practice Guide (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/nursing-protocols/nursing-practice-guide.pdf
    March 01, 2022 - .* • CHG bath documentation occurs once per calendar day • Provide staff educational huddles

  19. Handoffs and Handovers | PSNet

    psnet.ahrq.gov/glossary/handoffs-and-handovers
    September 13, 2021 - these transitions in care, the term "handovers" is often used to refer to the information transfer that occurs

  20. Using Probabilistic Risk Assessment to Model Medication System Failures in Long-term Care Facilities (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Comden.pdf
    January 01, 2003 - Event50 Facility hears correct dose and writes wrong dose on order Q:0.001 Gate363 Read back 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 … Borrowing also occurs when insurer preauthorization policies delay acquisition of clinically important … Advances in Patient Safety: Vol. 2 404 Sometimes borrowing occurs to avoid surveyor citations for
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