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1. Appendix, Develop a Flowchart of Your Current Medication Reconciliation Process | Agency for Healthcare Research and Quality
   ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/match/appendix/app-5.html
   July 01, 2022 - When does reconciliation occur? … When does the followup occur? … When does the followup occur? … When does this occur? … When does the followup occur?

2. Practice Self-Assessment Tool for Opioid Use in Older Adults (pdf file)
   ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/opioids/compendium/opioids-compendium-self-assessment.pdf
   December 01, 2023 - …occur infrequently. …occur regularly but rarely impact care planning. … …occur regularly and result in changes to care plans and chronic pain management. … …occur infrequently. …occur regularly but rarely impact care planning. … …occur regularly and result in changes to care plans and chronic pain management. … …occur infrequently. …occur regularly but do not impact care planning.

3. Module 1: An Overview of the CANDOR Process | Agency for Healthcare Research and Quality
   ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes1.html
   August 01, 2022 - This table demonstrates just a few of the changes that must occur to realize the goals of the CANDOR … After the CANDOR System Activation occurs, the 3 rd and 4 th components should occur simultaneously … The following activities should occur at this time: the Core Team will schedule and complete interviews … The second part should occur within 30-45 business days after a CANDOR event has been identified. … Resolution of the event can only occur after Event Investigation and Analysis has been completed.

4. Action Planning Worksheets | Agency for Healthcare Research and Quality
   ce.effectivehealthcare.ahrq.gov/teamstepps/instructor/essentials/implguide2.html
   November 01, 2018 - Understands the processes of care within workspace where changes will occur. … When does the "problem" occur? … When will the improvement occur? Within what timeframe?   … When will the improvement occur? Within what timeframe?   … When will the improvement occur? Within what timeframe?  

5. TeamSTEPPS for Office-Based Care: Implementation Workbook | Agency for Healthcare Research and Quality
   ce.effectivehealthcare.ahrq.gov/teamstepps/officebasedcare/impworkbook.html
   December 01, 2015 - Understands the processes of care within workspace where changes will occur. … When does the "problem" occur? … When will the improvement occur? Within what timeframe?   … When will the improvement occur? Within what timeframe?   … When will the improvement occur? Within what timeframe?    

6. Module 1: Communication and Optimal Resolution (CANDOR) Toolkit Module 1: An Overview of the CANDOR Process
   ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/module1-overview.pptx
   May 19, 2016 - This table demonstrates just a few of the changes that must occur to realize the goals of the CANDOR … After the CANDOR System Activation occurs, the 3rd and 4th components should occur simultaneously. … Let’s examine the specific activities that occur during the 4th component of the CANDOR process, Event … The second part should occur within 30-45 business days after a CANDOR event has been identified. … Resolution of the event can only occur after Event Investigation and Analysis has been completed.

7. TeamSTEPPS for Office-Based Care Implementation Workbook (pdf file)
   ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/officebasedcare/impworkbook.pdf
   December 11, 2015 - clinical subject matter  Understands the processes of care within workspace where changes will occur … When will the improvement occur? Within what timeframe? … When will the improvement occur? Within what timeframe? … When will the improvement occur? Within what timeframe? … Write down the process steps as they currently occur and identify who is doing what, when, with what

8. TeamSTEPPS 2.0 Briefing Exercise Sheet (pdf file)
   ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module4/exbriefing.pdf
   March 20, 2014 - When will the briefing occur? iii. Where will the briefing occur? B.

9. Briefing Exercise Sheet (pdf file)
   ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module4/ts2-0ltc_module4_briefing_exsheet.pdf
   April 24, 2017 - When will the briefing occur? iii. Where will the briefing occur? B.

10. Acute Care Asymptomatic Bacteriuria and Urinary Tract Infections
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/allergies-slides.pptx
    September 01, 2022 - testing or evidence of hemolysis (jaundice, dark urine) or thrombocytopenia (petechiae) Most commonly occur … Serum sickness Vasculitis Palpable purpura Joint pain Urticaria Lymphadenopathy Fevers Most commonly occur … Ambulatory Care Allergy History: Timing3,12 How long after starting the antibiotic did the reaction occur … Type 1 allergies occur after the first or second dose Other types usually occur days later How long … ago did the reaction occur?

11. Presentation: Program Overview
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/learn-from-defects-slides.pptx
    January 01, 2017 - and second-order problem solving List contributing factors that make defects in care more likely to occur … you identify contributing factors Use the “5 Whys” technique Why 1—Why did this contributing factor occur … Why 2—Why did “Why 1” occur? Why 3—Why did “Why 2” occur? Why 4—Why did “Why 3” occur? … Why 5—Why did “Why 4” occur? … Does it occur rarely or have a high likelihood of reoccurring?

12. Learn From Defects in Care of Mechanically Ventilated Patients: Slide Presentation | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/hai/tools/mvp/modules/cusp/learn-from-defects-slides.html
    February 01, 2017 - List contributing factors that make defects in care more likely to occur. … Why 1—Why did this contributing factor occur? Why 2—Why did “Why 1” occur? … Why 3—Why did “Why 2” occur? Why 4—Why did “Why 3” occur? Why 5—Why did “Why 4” occur? … Does it occur rarely or have a high likelihood of reoccurring?

13. Pocket Cards_4 Moments (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/four-moments/poster-three-options.pdf
    November 01, 2019 - Moment 4 should occur as soon as it is clear what infectious process is being treated and the patient … Moment 4 should occur as soon as it is clear what infectious process is being treated and the patient

14. 20 Tips To Help Prevent Medical Errors: Patient Fact Sheet | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/questions/resources/20-tips.html
    November 01, 2020 - 20 Tips To Help Prevent Medical Errors: Patient Fact Sheet Medical errors can occur … But medical errors can occur anywhere in the health care system: In hospitals, clinics, surgery centers … What do I do if they occur?

15. Development and Validation of the Medication Administration Error Reporting Survey (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Wakefield2.pdf
    January 01, 2003 - Five subscales emerged for “reasons why MAE occur”; four subscales emerged for “reasons why MAE are … medication administration errors occur. … Reasons why medication errors occur (19 items in 1994 and 29 in subsequent surveys). 2. … In the first content area, “why MAEs occur,” five factors emerged. … Nurses’ perceptions of why medication administration errors occur.

16. PowerPoint Presentation
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/fallpxoverview.pptx
    October 01, 2017 - Nursing homes investigate adverse events after they occur. … Is it possible to intervene before adverse events occur? … Analysis: Reviews process for conducting investigations or root cause analyses when adverse events occur … When will the meeting occur? Which reports will be used at the meeting? … How will communication occur with other disciplines to confirm changes in care?

17. PowerPoint Presentation
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-factraining-slides.pptx
    November 01, 2016 - Nursing homes investigate adverse events after they occur. … Is it possible to intervene before adverse events occur? … Analysis: Reviews process for conducting investigations or root cause analyses when adverse events occur … When will the meeting occur? Which report(s) will be used at the meeting? … How will communication occur with other disciplines to confirm changes in care?

18. PowerPoint Presentation
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruprev/factraining_slides.pptx
    December 01, 2014 - Nursing homes investigate adverse events after they occur. … Is it possible to intervene before adverse events occur? … Analysis: Reviews process for conducting investigations or root cause analyses when adverse events occur … When will the meeting occur? Which report(s) will be used at the meeting? … How will communication occur with other disciplines to confirm changes in care?

19. PowerPoint Presentation
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/ontime-preventablehospitaledvisits-overview.pptx
    May 01, 2017 - Nursing homes investigate adverse events after they occur. … Is it possible to intervene before adverse events occur? … Analysis: Reviews process for conducting investigations or root cause analyses when adverse events occur … When will the meeting occur? Which reports will be used at the meeting? … How will communication occur with other disciplines to confirm changes in care?

20. Introduction | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/maternal-mortality-1.html
    September 01, 2021 - 700 birthing people dying every year from pregnancy-related causes. 7 One-third of maternal deaths occur … The brief focuses on the maternal events that occur during childbirth and up to a week postpartum, with