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  1. cahps.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
  2. cahps.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
  3. cahps.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 …
  4. cahps.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.
  5. cahps.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
  6. cahps.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
  7. cahps.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?
  8. cahps.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
  9. cahps.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 …
  10. cahps.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
  11. cahps.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…
  12. cahps.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
  13. cahps.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
  14. cahps.ahrq.gov/patient-safety/reports/dxsafety-issuebriefs.html
    January 01, 2024 - Resources AHRQ Papers on Diagnostic Safety Topics Diagnostic errors occur
  15. cahps.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
  16. cahps.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2013-materials/teamstepps-monthly-webinar-dec2013.pptx
    January 01, 2013 - Technology Example “…if [people] accept the need to adopt a particular practice, implementation should occur … ☐  Yes        ☐  No             When  did  the  briefing  occur?  
  17. cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/infographicposter-final508_0.pdf
    July 12, 2018 - admissions are related to an adverse drug event An estimated 160 million medication errors occur
  18. cahps.ahrq.gov/teamstepps/instructor/fundamentals/module2/slteamstruct.html
    July 01, 2018 - Teamwork cannot occur in the absence of a clearly defined team. … Where did the breakdowns occur between the components of this multi-team system? 
  19. Ldusafety Facguide (doc file)

    cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety_facguide.docx
    May 01, 2017 - Errors associated with schematic tasks are labeled “slips” and occur because of lapses in concentration … Errors associated with failures of attentional behavior are labeled “mistakes” and often occur because … Checklists are cognitive aids that have numerous practical benefits, including reducing slips that occur … In practice, steps listed may not occur sequentially.
  20. cahps.ahrq.gov/teamstepps/rrs/rrs_slides/rrsslides.html
    July 01, 2018 - Identify Your RRS Structure RRS Execution Detection Detection: STEP Assessment Where can Detection occur … Return to Top Where can Detection occur? … Detection can occur from a variety of sources or concerns Image: Activator penguin holding oversize … Return to Top Evaluation: Debriefs Debriefs occur right after the event and are conducted by the

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