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61. Appendix G. Safety and Adverse Events | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/hai/universal-icu-decolonization/universal-icu-apg.html
    September 01, 2013 - In rare case reports, anaphylaxis can occur (difficulty breathing; tightness in the chest; swelling of … For example, this may occur if CHG enters the ear canal and the patient has a perforated (punctured)

62. Understand the Science of Safety for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/understand-sci-fac-guide.html
    July 01, 2023 - Say: Errors occur within the health care setting because health care professionals are human, and humans … Providers, executives, and managers need to understand why errors occur. … Errors occur because medicine is still treated as an art, not a science. … In analyzing how errors occur, frontline providers must recognize the scientific nature of medicine. … Errors also occur because systems frequently do not catch mistakes before they reach the patient.

63. Surge in Drug Shortages Occurred in Wake of Pandemic, Study Finds | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/news/newsletters/e-newsletter/908.html
    April 01, 2024 - 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 …

64. PowerPoint Presentation
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module11/ts2-0ltc_module11_slides_implementation.pptx
    February 03, 2006 - When and where will the improvements occur? … When will the training sessions occur and for how long? Where will the sessions occur?

65. newbref
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module11/slimplement.pptx
    February 03, 2006 - When and where will the improvements occur? … When will the training sessions occur and for how long? Where will the sessions occur?

66. Slide 1
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/officebasedcare/module11/11_ts_office_impplan.pptx
    January 20, 2006 - When and where will the improvements occur? … When will the training sessions occur and for how long? Where will the sessions occur?

67. Supplemental-Utilization-Hp-Child-2158-13A (doc file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/item-sets/HP/supplemental-utilization-hp-child-2158-13a.docx
    December 08, 2017 - Some items cover events that occur with low frequency in the general population.

68. Supplemental-Utilization-Hp-Adult-2157-13A (doc file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/item-sets/HP/supplemental-utilization-hp-adult-2157-13a.docx
    December 08, 2017 - Some items cover events that occur with low frequency in the general population.

69. Quick Reference Guide to TeamSTEPPS Action Planning | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/teamstepps/instructor/reference/quickrefguide.html
    March 01, 2014 - achieved, who will be involved (whose behavior will change), and when and where the change will occur … Write the process steps as they currently occur, identifying who is doing what, when, with what tools … each trainee audience, including who will attend, what will be taught, when and where sessions will occur

70. newbref
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module2/slteamstructure.pptx
    February 02, 2006 - TEAMSTEPPS 05.2 Mod 2 2.0 Page ‹#› Team Structure 2 Page ‹#› Team Structure Teamwork cannot occur … Core team Coordinating team Contingency team Ancillary and support services Where did the breakdowns occur

71. AHRQ Tribal Consultation Policy | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/cpi/about/mission/strategic-plan/tribal-consultation-policy.html
    August 01, 2014 - Policy It is the policy of AHRQ that consultation with Federally-recognized Indian Tribes will occur … Consultation shall occur on a regular basis and may occur on an "as needed" basis as well. … The Agency will also take part in the Department's annual national Tribal budget consultations which occur … Other types of meetings and/or conferences occur in which tribal leaders/representatives and Agency leaders

72. Fallpxtool3A (doc file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallpxtoolkit/fallpxtool3a.docx
    January 28, 2013 - Background: The purpose of this tool is to provide an overview of how fall prevention care processes could occur

73. Guide Promotional Postcard (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/pfeprimarycare-infographic.pdf
    April 01, 2018 - admissions are related to an adverse drug event An estimated 160 million medication errors occur

74. TeamSTEPPS 2.0: Module 11. Implementation Workshop | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/teamstepps/instructor/fundamentals/module11/igimplement.html
    March 01, 2014 - Write down the process steps as they currently occur and identify who is doing what, when, and with which … intervention: what will be achieved, who will be involved, and when and where the change will occur … Outcome aims focus on changes that occur because your staff carries out the intervention. … Write down the process steps as they currently occur and identify who is doing what, when, with what … When the training sessions will occur and for how long. Where the sessions will occur.

75. Health Care Simulation to Advance Safety: AHRQ Issue Brief (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/publications/files/simulation-brief.pdf
    February 01, 2015 - mistakes safely, and to learn from these mistakes while avoiding patient harms that might otherwise occur … More focused forms of feedback with the guidance of an instructor are likely to occur during a debrief … clinicians’ inquiries, they may evoke a wide range of emotional and behavioral characteristics that occur … Because of the uncertainty, complexity, and rapidly emerging conditions that occur in many health care … Given that unexpected events will occur, there are lessons to be learned regarding their anticipation

76. Supplemental-Providertype-Cgcahps-Adult-2357-10A (doc file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/item-sets/CG/supplemental-providertype-cgcahps-adult-2357-10a.docx
    September 22, 2017 - Some items cover events that occur with low frequency in the general population.

77. A Visual Computer Interface Concept for Making Error Reporting Useful at the Point of Care (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Singh_69.pdf
    April 04, 2008 - steps in developing a culture of safety is the recognition by staff and clinicians of errors that occur … These processes are recognized to occur in a cyclical fashion, as shown by the clockwise progression … system, especially with respect to errors and opportunities for errors, including errors that may occur … In the emergency room (circle no. 2), similar cycle(s) of care occur, starting with Assessment (point … , contributors that might be present, and consequences that can occur, thereby improving situational

78. Data Measures Guide (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/vae/datameasures-guide.pdf
    January 01, 2017 - , o 3 have adverse event (9) occur, o 2 have adverse event (18) occur, and o 3 have adverse event … (20) occur. … ) occur and 30% of the patient days had adverse event (20) occur Target Accurate documentation of … (20) occur. … ) occur and 30% of the patient days had adverse event (20) occur Target Accurate documentation of

79. The Quick Reference Guide to TeamSTEPPS Action Planning | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/teamstepps/instructor/essentials/implguide3.html
    November 01, 2018 - achieved, who will be involved (whose behavior will change), and when and where the change will occur … during which the problem, challenge or opportunity occurs - write the process steps as they currently occur … trainee audience including who will attend, what will be taught, when and where sessions will occur

80. Four Moments of Antibiotic Decision Making Explained (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/four-moments-explained.pdf
    June 01, 2021 - Four Moments of Antibiotic Decision Making Explained Moment 1 occurs when a resident is assessed for a change in status and there is a concern for infection. Sometimes long-term care staff recognize that something is not quite right with the resident but aren’t clear on what is wrong. The person doing the assessmen…