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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/055-guide-nursing-practice.docx
October 01, 2024 - .*
· CHG bath documentation occurs once per calendar day.
· Escalation support pathway in effect for
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psnet.ahrq.gov/issue/complications
November 28, 2018 - issue explore complications in anesthesia, including how providers can respond when a complication occurs
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psnet.ahrq.gov/issue/sailing-too-close-wind-how-harnessing-patient-voice-can-identify-drift-towards-boundaries
February 28, 2024 - Normalization of deviance occurs when poor practices are common throughout an organization despite
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psnet.ahrq.gov/web-mm/coming-err-missed-diagnosis-patient-recurrent-pneumothorax
December 14, 2022 - Schiff, MD Lymphangioleiomyomatosis or LAM is a rare cystic lung disease that occurs primarily in women … The sporadic form, which occurs in 3.3-7.7/million women, and the inherited form of LAM, which may occur … Since LAM occurs in young women and asthma is a common cause of dyspnea in this population, it is not … LAM is a rare cystic lung disease that occurs more commonly in young women.
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psnet.ahrq.gov/node/41924/psn-pdf
April 05, 2013 - may-prompt-complex
Some institutions have implemented disclosure-and-resolution programs whenever an error occurs
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/overviewhandouts2.html
December 01, 2017 - For every meeting that occurs at your facility, indicate how often it occurs, who leads the meeting,
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/improve/coordination/webinar04/formative_evaluation_webinar.pptx
July 15, 2013 - stakeholders in defining problem and potential solutions
9
Implementation-Focused
Formative Evaluation
Occurs … replicate implementation strategy in other settings
10
Progress-Focused
Formative Evaluation
Occurs
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/patfamilyengagement/CUSP-Patient-Family-Engagement.pptx
May 01, 2013 - postdischarge complications and avoidable readmissions
IDEAL Discharge
What if an Adverse Event Occurs … to help and care for patients without harming them, but adverse events happen
When an adverse even occurs
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/impmenu.html
January 01, 2015 - The worksheet also includes columns for identifying if a given suggested meeting already occurs or whether
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/assess.html
November 01, 2017 - in care plans, and
Carry out investigations, including root cause analysis, when an injurious fall occurs
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/best-practices/respiratory-facilitator-guide.pdf
November 01, 2019 - Commentary Slide Number and Slide
The Four Moments of Antibiotic Decision
Making
SAY:
Moment 3 occurs … Aspiration Pneumonia
SAY:
If an aspiration event progresses to aspiration
pneumonia, this generally occurs … Slide 30
The Four Moments of Antibiotic Decision
Making
SAY:
Moment 3 occurs after a day … If rapid
improvement occurs, antibiotics can be discontinued.
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psnet.ahrq.gov/issue/corridor-care-emergency-department-managing-patient-care-non-clinical-areas-safely-and
May 19, 2021 - This article outlines how ED overcrowding occurs and provides several approaches to mitigate risks and
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psnet.ahrq.gov/issue/err-human-apologize-hard
September 28, 2022 - related actions that aid in rebuilding trust between clinicians, patients, and families when error occurs
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psnet.ahrq.gov/issue/inattentional-blindness-medicine
March 31, 2021 - Inattentional blindness occurs when a person is focused so intently on one task that they miss other
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psnet.ahrq.gov/issue/ashp-guidelines-managing-drug-product-shortages
September 06, 2023 - assessments, establishing a drug shortage team, and communicating with patients and providers when a shortage occurs
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psnet.ahrq.gov/issue/restorative-just-culture-exploration-enabling-conditions-successful-implementation
February 08, 2023 - culture aim to balance organizational and individual accountability and responsibility when an error occurs
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psnet.ahrq.gov/issue/patient-and-clinician-experiences-uncertainty-diagnostic-process-current-understanding-and
March 11, 2020 - article provides an overview of the literature on diagnosis-related uncertainty, where uncertainty occurs
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psnet.ahrq.gov/issue/more-hospitals-move-confront-medical-errors-head
June 21, 2023 - clinicians, health system leaders, and improvement experts to discuss actions after medical error occurs
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psnet.ahrq.gov/node/855058/psn-pdf
October 31, 2023 - findings indicated that verbal violence from patients (e.g., insults, threats, screaming, cursing) occurs … I think the most concerning, at least
in the immediate sense, is the violence that occurs from patients … leaders will act on reported information, they are
more likely to report workplace violence when it occurs … would you recommend that organizations use to
better understand how, where, and why workplace violence occurs … if they’re trained on organizational procedures and policies to address
workplace violence when it occurs
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www.ahrq.gov/patient-safety/reports/engage/interventions/index.html
June 01, 2023 - Warm Handoff : a transfer of care between two members of the health care team, where the handoff occurs