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Showing results for "occurs".

  1. Screening for Gestational Diabetes: Clinician Summary for USPSTF Recommendation (pdf file)

    www.uspreventiveservicestaskforce.org/home/getfilebytoken/qPSAJPnBVmzFneXUDMRJfs
    August 01, 2021 - Typically in the US, screening occurs prior to 28 weeks of gestation; however, it can occur later in

  2. Warm Handoff: Intervention | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/reports/engage/interventions/warmhandoff.html
    June 01, 2023 - A warm handoff is a transfer of care between two members of the health care team, where the handoff occurs

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49581/psn-pdf
    March 21, 2009 - operationalized; however, the far-reaching effects of these decisions often go undetected until an error occurs … The error occurs when individuals fall victim to the flaws within the system and mistakes are made. … Standardize patient-centric handoff communication, and mandate that it occurs at the time of nursing

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49628/psn-pdf
    June 01, 2011 - The most commonly cited preoperative risk is bleeding, which occurs in up to 3% of patients. … The highest risk of return to the operating room to control hemorrhage occurs one week postoperatively … The most common complication is postoperative bleeding, which occurs in less than 10% of patients.

  5. Addressing the Loss of Trust in Safety Culture. | PSNet

    psnet.ahrq.gov/issue/addressing-loss-trust-safety-culture
    February 08, 2017 - needed to ensure that patients can trust the health care system to hold those accountable when error occurs

  6. Ambulatory medication errors and adverse events involved in medicine-related malpractice cases from 2011 to 2021. | PSNet

    psnet.ahrq.gov/issue/ambulatory-medication-errors-and-adverse-events-involved-medicine-related-malpractice-cases
    November 18, 2016 - Most medication safety research occurs in the inpatient setting, with less focus on ambulatory care.

  7. Ten years later, alarm fatigue is still a safety concern. | PSNet

    psnet.ahrq.gov/issue/ten-years-later-alarm-fatigue-still-safety-concern
    October 25, 2023 - Alarm (or alert) fatigue occurs when clinicians ignore alarms, usually due to the majority being invalid

  8. Standardized assessment of medication reconciliation in post-acute care. | PSNet

    psnet.ahrq.gov/issue/standardized-assessment-medication-reconciliation-post-acute-care
    December 16, 2020 - Medication reconciliation (MR) occurs during transitions of care and is the process of reviewing a patient

  9. The effect of clinical experience on the error rate of emergency physicians. | PSNet

    psnet.ahrq.gov/issue/effect-clinical-experience-error-rate-emergency-physicians
    November 16, 2022 - often examined by conducting case reviews or root cause analyses when an undesired patient outcome occurs

  10. Racial and ethnic harm in patient care is a patient safety issue. | PSNet

    psnet.ahrq.gov/issue/racial-and-ethnic-harm-patient-care-patient-safety-issue
    October 21, 2020 - ethnically marginalized patients, such as antiracism education and addressing harm promptly when it occurs

  11. Stakeholder perceptions of and attitudes towards problematic polypharmacy and prescribing cascades: a qualitative study. | PSNet

    psnet.ahrq.gov/issue/stakeholder-perceptions-and-attitudes-towards-problematic-polypharmacy-and-prescribing
    July 10, 2019 - An unintentional prescribing cascade occurs when a medication side effect is misinterpreted as a new

  12. Organizational learning: health care leaders need to design structures and processes that enhance collective learning. | PSNet

    psnet.ahrq.gov/issue/organizational-learning-health-care-leaders-need-design-structures-and-processes-enhance
    November 18, 2020 - The authors argue that true learning in health organizations occurs through a cyclical, dualistic, and

  13. Team cognition in handoffs: relating system factors, team cognition functions and outcomes in two handoff processes. | PSNet

    psnet.ahrq.gov/issue/team-cognition-handoffs-relating-system-factors-team-cognition-functions-and-outcomes-two
    February 16, 2022 - This qualitative study explores how team cognition occurs during care transitions and interprofessional

  14. Creating highly reliable health care: how reliability-enhancing work practices affect patient safety in hospitals. | PSNet

    psnet.ahrq.gov/issue/creating-highly-reliable-health-care-how-reliability-enhancing-work-practices-affect-patient
    January 12, 2022 - within high-risk industries that have adopted processes to detect and address failures before harm occurs

  15. The Inside of a Time Out | PSNet

    psnet.ahrq.gov/web-mm/inside-time-out
    March 01, 2004 - procedure is not started if a member of the team has concerns.( 2 ) In some institutions, the time out occurs … If the time out occurs at the time of incision, the surgeon is already scrubbed in, leaving only the … time out is for the team to collectively discuss the case, but, given the requirements to ensure it occurs … With regard to timing, it seems that the closer to actual incision time the time out occurs, the less

  16. Exhibit 3.2. Grand Hospital Center | Agency for Healthcare Research and Quality

    www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit3-2.html
    November 01, 2014 - Communication about Lean: Ensure communication about changes resulting from project occurs.

  17. Artificial lung ventilation tube connected to the patient in the bed (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/044-vap-prevention-essential.docx
    October 01, 2024 - If condensation occurs, drain away from patient.

  18. Implementation-Guide-Appendix-O (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/impl-guide/implementation-guide-appendix-o.docx
    June 02, 2025 - CAUTI Event Report Template When a catheter-associated urinary tract infection (CAUTI) occurs on your

  19. Executive Summary | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/hospital/vtguide/guidesum.html
    March 01, 2016 - While VTE sometimes occurs despite the best available prophylaxis, there are many lost opportunities

  20. Executive Summary | Agency for Healthcare Research and Quality

    www.ahrq.gov/es/patient-safety/settings/hospital/vtguide/guidesum.html
    March 01, 2016 - While VTE sometimes occurs despite the best available prophylaxis, there are many lost opportunities
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