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  1. ce.effectivehealthcare.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
  2. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/module5-response-disclosure-notes.pptx
    August 21, 2015 - not an isolated event, since there are many different points at which disclosure conversations can occur
  3. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/supporting/partner-care.docx
    May 01, 2017 - · Nurse shift changes occur when nurses who are going off duty share information about you with nurses
  4. Fallpxtool5A (doc file)

    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallpxtoolkit/fallpxtool5a.docx
    January 29, 2013 - Ensure timescales for assessing and preventing falls are tailored to when falls are most likely to occur
  5. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/item-sets/HP/supplemental-health-promotion-education-hp-adult-2157-11a.docx
    December 08, 2017 - Some items cover events that occur with low frequency in the general population.
  6. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy2/Strat2_Tool_1_Be_Partner_508.pdf
    May 24, 2013 - • Nurse shift changes occur when nurses who are going off duty share information about you with
  7. ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/resource/nicu/packet/apb.html
    December 01, 2013 - UTI and urolithiasis do not occur any more frequently than in general population. … If the ductus is open at the time of hospital discharge, followup with a cardiologist should occur within … Earlier followup should occur if poor weight gain, difficulty feeding, and tachypnea develop. … Management If spontaneous closure does not occur, closure should be performed to: Eliminate pulmonary
  8. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/learning-from-antibiotic-adverse.docx
    June 01, 2021 - AHRQ Safety Program for Improving Antibiotic Use Learning From Antibiotic-Associated Adverse Events An antibiotic-associated adverse event is any event or situation that you would not want to happen again because it either caused your patient harm or had the potential to cause harm. The purpose of this tool is to provi…
  9. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallpxtoolkit/fallpxpresentation.pptx
    October 01, 2008 - 6000 Falls Facts One in three U.S. adults age 65 or older falls each year 10% of older adult falls occur … materials from ECRI Institute, (610) 825-6000 Rounding to Assist with Patient Needs Many patient falls occur … Falls are more likely to occur when staff members have not been apprised of a patient’s risk of falling
  10. ce.effectivehealthcare.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?
  11. ce.effectivehealthcare.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/pf-engagement-fac-guide.html
    July 01, 2023 - Slide 17: Engaging After Adverse Events Say: Adverse events occur when a patient is harmed as a … Rarely does an adverse event occur as a result of intent.
  12. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Encinosa.pdf
    January 01, 2003 - examined 14 potentially preventable adverse medical events defined by the PSI methodology that can occur
  13. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Riley_58.pdf
    April 02, 2008 - We selected obstetrics crises to study team performance for several reasons: • They occur in a compressed … regarding the nature of team formation and reformation in health care and leadership transfer that occur … At the same time, more complications/crisies could occur in real life situations.
  14. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Devine.pdf
    July 01, 2003 - ambulatory care setting is complex, and that there are numerous points in that process where errors can occur
  15. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module4/igleadership.pdf
    March 10, 2014 - which information must be communicated, a leader must be clearly designated, and mutual support must occur … Did the items on this checklist occur? If not, what was not done? … When would the briefing occur? Who would be expected to attend? … In addition, information updates within the team should occur as often as necessary. … difficult to find time for such reviews in health care, TeamSTEPPS advocates that after action reviews occur
  16. ce.effectivehealthcare.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.
  17. Slide 1 (pdf file)

    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2016-materials/teamstepps-monthly-webinar-december2016.pdf
    January 01, 2016 - TEAMSTEPPS 05.2Mod 1 05.2 Page 15 TeamSTEPPS® Slide 15 Reducing Workplace Violence Where May Violence Occur … Violence may occur anywhere in the health care facility, but it is most frequent in the following areas … Workplace Violence Communication and Teamwork Slide Number 13 Team Structure Where May Violence Occur
  18. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Mohr.pdf
    February 01, 2004 - A study conducted by the American Academy of Family Physicians (AAFP) confirms that errors occur in … , in part, because they often do not see the consequences of the errors because those consequences occur … ambulatory care and the aspects of ambulatory medical care in which they occur. … Discussion The LEAP study confirms that medical errors occur in ambulatory pediatric settings. … The LEAP study documents that errors occur in ambulatory settings, most frequently in the context of
  19. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Drews_15.pdf
    February 26, 2008 - Among the areas where errors occur frequently is the intensive care unit (ICU). … human error in U.S. hospitals each year.1 Critical care is one of the areas in which human errors occur … a more proactive strategy of error management; its goal is to anticipate where and how errors may occur … Our initial finding is consistent with the existing literature on error in the ICU: Errors not only occur … in the ICU, but they occur rather frequently, as reflected in the high mean nurse estimates of 6.35
  20. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/one-pager-side-effects.pdf
    June 01, 2021 - Common side effects and adverse reactions • Gastrointestinal disturbances (such as diarrhea) occur

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