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21. How To Implement the Pressure Injury Prevention Program in Your Organization
    ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module4/module4_pu-implementation_slides.pptx
    November 20, 2014 - Unit staff tell the Wound Care Team about high-risk patients or if skin problems occur. … 19 Practice Insight Staff Turnover 20 Communication Patterns Good communication needs to occur

22. Mod5-Disclosure-Checklist (pdf file)
    ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/mod5-disclosure-checklist.pdf
    April 01, 2016 - tool: Use Part I of the checklist to prepare for the initial disclosure conversation, which should occur

23. TeamSTEPPS 2.0 Module 11: Implementation Planning
    ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/teamstepps/instructor/onlinecourse/tsonlinemodule11.pptx
    November 02, 2018 - When and where the improvements will occur? … Outcome aims focus on changes that occur because your staff carries out the intervention. … When will the training sessions occur and for how long? Where will the sessions occur? … When will training occur and how long will the sessions last? … When will training occur and how long will the sessions last?

24. The How-To’s of Hand Hygiene | Agency for Healthcare Research and Quality
    ahrqpubs.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/education-bundles/infection-prevention/hand-hygiene/hand-hygiene-slides.html
    March 01, 2017 - Slide 3: Health Care Workers' Hands Spread Infections 1 1-3 million serious infections estimated to occur … Hand contamination may occur as a result of small undetected holes in gloves. … Hand contamination may occur during glove removal.

25. Strategy 2: Communicating for Improve Quality (Tool 1) (doc file)
    ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy2/Strat2_Tool_1_Be_Partner_508.docx
    February 10, 2011 - Nurse shift changes occur when nurses who are going off duty share information about you with nurses

26. Module 7: Resolution | Agency for Healthcare Research and Quality
    ahrqpubs.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes7.html
    August 01, 2022 - Slide 1 Say: When adverse patient events occur, the patient and their family are looking for

27. Fall Prevention Toolkit (doc file)
    ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module5/module5_tools.docx
    August 03, 2017 - Ensure timescales for assessing and preventing falls are tailored to when falls are most likely to occur … Observations at the bedside should occur at the time of day when most patients who are well enough would

28. Saving Lives and Saving Money: Hospital-Acquired Conditions Update | Agency for Healthcare Research and Quality
    ahrqpubs.ahrq.gov/hai/pfp/2014-final.html
    January 01, 2018 - Skip to main content An official website of the Department of Health and Human Services Careers Contact Us Español FAQs Search all AHRQ sites Search small Search Menu …

29. Patient and Family Engagement | Agency for Healthcare Research and Quality
    ahrqpubs.ahrq.gov/hai/cusp/modules/patient-family-engagement/notes.html
    September 01, 2013 - Introduction to Adverse Events Say: Adverse events occur when a patient is harmed as a result of … Rarely does an adverse event occur as a result of intent.

30. Module 5: Response and Disclosure | Agency for Healthcare Research and Quality
    ahrqpubs.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/notes.html
    August 01, 2022 - not an isolated event, since there are many different points at which disclosure conversations can occur

31. NPSD Data Spotlight - Patient Safety and COVID-19: A Qualitative Analysis of Concerns During the Public Health Emergency (pdf file)
    ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-ptsafety-and-covid-19.pdf
    November 01, 2021 - Many areas for errors to occur especially with increase in test volume. … These policy- and procedure-related events are more likely to occur in a rapidly changing environment

32. Event Investigation and Analysis Guide: Appendix D | Agency for Healthcare Research and Quality
    ahrqpubs.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apd.html
    August 01, 2022 - Could this type of communication failure occur in the future during normal working conditions? … Why did they occur? Is there any opportunity to overcome the barriers?

33. System-Focused Event Investigation and Analysis Guide | Agency for Healthcare Research and Quality
    ahrqpubs.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4.html
    August 01, 2022 - In addition, learning about system vulnerabilities before they occur is critical. … The CANDOR Response Team is responsible for conducting a preliminary review, which should occur within … The preliminary review should occur at the event location. … understanding of the event: if individual interviews, appropriate information gathering, and observations occur … Please note that the bulk of the time and effort of the event review process should occur during the

34. National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data From National Efforts To Make Health Care Safer | Agency for Healthcare Research and Quality
    ahrqpubs.ahrq.gov/hai/pfp/2015-interim.html
    December 01, 2016 - Skip to main content An official website of the Department of Health and Human Services Careers Contact Us Español FAQs Search all AHRQ sites Search small Search Menu …

35. Well-Child Visits on the Rise, But Disturbing Gaps Remain for Underserved Populations | Agency for Healthcare Research and Quality
    ahrqpubs.ahrq.gov/news/newsletters/e-newsletter/828.html
    August 01, 2022 - An estimated 250,000 diagnostic errors occur annually in U.S. hospitals. … interactions are responsible for up to 14 percent of adverse drug reactions in hospitalized patients and occur

36. Final Data From National Efforts To Make Care Safer, 2010-2014 (pdf file)
    ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/2014FinalHACreport4Web-13Dec2016.pdf
    December 01, 2016 - Final Data From National Efforts To Make Care Safer, 2010-2014 December 2016 Saving Lives and Saving Money: Hospital-Acquired Conditions Update Final Data From National Efforts To Make Care Safer, 2010-2014 Summary Final estimates for 2014 show a sustained 17 percent decline in hospital-acquired conditions…

37. Selected Best Practices and Suggestions for Improvement (pdf file)
    ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4n_combo_iqi-mortalityreview-bestpractices.pdf
    May 20, 2016 - community and the public on the estimation that between 48,000 and 98,000 deaths from medical errors occur …  Yes:  Did any of the following occur during hospitalization? …  Yes:  Did any of the following occur during the hospitalization (check all that apply) ∗ Death

38. Module 4: Teamwork and Communication: Facilitator Notes | Agency for Healthcare Research and Quality
    ahrqpubs.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module4/mod4-facguide.html
    March 01, 2017 - Slide 17: For Information Transfer – Handoffs Say: Handoffs occur during a change in assignment … A handoff may occur when a resident is first welcomed to the nursing home from the hospital or during … another staff member, even for a short timespan such as a lunch break, a structured communication should occur

39. AHRQ Papers on Diagnostic Safety Topics | Agency for Healthcare Research and Quality
    ahrqpubs.ahrq.gov/patient-safety/reports/dxsafety-issuebriefs.html
    January 01, 2024 - Resources AHRQ Papers on Diagnostic Safety Topics Diagnostic errors occur

40. AHRQ Quality and Safety Review System (QSRS) | Agency for Healthcare Research and Quality
    ahrqpubs.ahrq.gov/patient-safety/quality-measures/qsrs/index.html
    September 01, 2022 - Medicine report, To Err Is Human , revealed more than 15 years ago the extent of medical errors that occur