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1. Module 1: An Overview of the CANDOR Process | Agency for Healthcare Research and Quality
   healthcare411.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.

2. Action Planning Worksheets | Agency for Healthcare Research and Quality
   healthcare411.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?  

3. TeamSTEPPS Implementation Guide (pdf file)
   healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/essentials/implguide_0.pdf
   March 01, 2006 - Where will it occur?  What do we hope to achieve with a TeamSTEPPS Intervention? … for the event to occur. … When does the “problem” occur? … When will the improvement occur? Within what timeframe? … When will the improvement occur? Within what timeframe?

4. Implementation Guide for the CANDOR Process | Agency for Healthcare Research and Quality
   healthcare411.ahrq.gov/patient-safety/settings/hospital/candor/impguide.html
   August 01, 2022 - For example, more than 1.5 million preventable infections occur annually among inpatients. … While these two processes occur at the same time during the CANDOR process, they have been numbered for … While an initial disclosure conversation will occur within 60 minutes after the CANDOR event occurs, … a full disclosure will typically not occur until after the Event Investigation and Analysis has been … Figure 2: CANDOR Implementation Phases Phase I: Assessments Phase I activities should occur during

5. Human Factors in Surgery: Shifting the Paradigm on Patient Safety | Agency for Healthcare Research and Quality
   healthcare411.ahrq.gov/funding/grantee-profiles/grtprofile-catchpole.html
   December 01, 2022 - 4,000 annual “never events”—shocking medical errors, such as wrong-site surgery, that should never occur … Delivery  , focuses on reducing the 200,000 to 20 million anesthesia-related medication injuries that occur … Factors and Systems Integration in High Technology Surgery , explores the root causes of errors that occur

6. 6 Tk1 T2-Talking With Residents Family Members Checklist Version Final (pdf file)
   healthcare411.ahrq.gov/sites/default/files/wysiwyg/nhguide/6_TK1_T2-Talking_with_Residents_Family_Members_checklist_version_Final.pdf
   October 01, 2016 - There are five potential health problems that occur as a result of taking an antibiotic. 1. … • Although we cannot be certain that any of these problems will occur, it is important that you and

7. TeamSTEPPS 2.0 Quick Reference Guide to TeamSTEPPS Action Planning (pdf file)
   healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/reference/quickrefguide.pdf
   March 13, 2014 - be 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

8. Adverse Drug Events Occurring in U.S. Hospitals | Agency for Healthcare Research and Quality
   healthcare411.ahrq.gov/data/infographics/adverse-drug-events.html
   August 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 …

9. Advancing Diagnostic Safety: An AHRQ Leadership Conversation | Agency for Healthcare Research and Quality
   healthcare411.ahrq.gov/news/blog/ahrqviews/diagnostic-safety-conversation.html
   October 01, 2021 - just a subset of the data that are out there, and we have enough to confirm that diagnostic errors occur … DM: Why do diagnostic errors occur in the first place? … This focus can occur even when their current patient’s history or symptoms suggest a different diagnosis … Systemic errors, in contrast, can occur when processes within organizations aren’t designed well or don

10. Using Patient Input to Improve Diagnostic Safety | Agency for Healthcare Research and Quality
    healthcare411.ahrq.gov/funding/grantee-profiles/grtprofile-bell.html
    March 01, 2022 - Diagnostic errors occur in part because diagnosis itself is a multi-layered process, potentially involving … Documentation errors occur frequently, with about one in five patients reporting a perceived serious … Bell and her team developed and tested the framework for patient-reported diagnostic breakdowns that occur

11. Surge in Drug Shortages Occurred in Wake of Pandemic, Study Finds | Agency for Healthcare Research and Quality
    healthcare411.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 …

12. Quick Reference Guide to TeamSTEPPS Action Planning | Agency for Healthcare Research and Quality
    healthcare411.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

13. AHRQ Tribal Consultation Policy | Agency for Healthcare Research and Quality
    healthcare411.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

14. Health Care Simulation to Advance Safety: AHRQ Issue Brief (pdf file)
    healthcare411.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

15. The Quick Reference Guide to TeamSTEPPS Action Planning | Agency for Healthcare Research and Quality
    healthcare411.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

16. AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Electronic Fetal Monitoring (doc file)
    healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/safe-electronic/tool_safe-e-fetal-monitoring.docx
    May 01, 2017 - determined, and staff should know what resources are available should a sudden change in patient status occur … Recurrent decelerations: occur with > 50% contractions in any 20-min window. … Intermittent decelerations: occur with < 50% contractions in any 20-min window. … Timing: may occur with or without contractions. … Timing: In most cases, the onset, nadir, and recovery occur after the beginning, peak, and ending of

17. Module 6: Care for the Caregiver | Agency for Healthcare Research and Quality
    healthcare411.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes6.html
    August 01, 2022 - Stages 1 through 3 may occur individually or simultaneously. … The reliving of the event is also known as a "tripping" or "triggering" event and can occur when the … An example of the emotions and thoughts that can occur at this stage from a second-victim are in the … The second-victim understands that disclosure of the event will occur with the patient and/or family … 21 Say: The following videos will help you understand how a peer support interaction can occur

18. Four Moments of Antibiotic Decision Making | Agency for Healthcare Research and Quality
    healthcare411.ahrq.gov/antibiotic-use/acute-care/four-moments/index.html
    November 01, 2019 - This can occur as early as after the first day the patient is on antibiotics; thus, the Moment 3 questions … Moment 4 should occur when the patient’s diagnosis becomes clear.

19. Selected Best Practices and Suggestions for Improvement (pdf file)
    healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4k_combo_psi14-dehiscence-bestpractices.pdf
    May 20, 2016 - Recommended Practice: Postoperative Wound Assessment • Documentation of the surgical wound should occur … 48 hours after surgery to establish a baseline.1,2,7 • Repeat assessment should occur every shift … Education should occur upon hire, annually, and when this protocol is added to job responsibilities.1

20. Selected Best Practices and Suggestions for Improvement (pdf file)
    healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4b_combo_psi05-foreignbody-bestpractices.pdf
    November 01, 2012 - foreign objects can include perforation of the bowel, sepsis, and even death.1 These complications can occur … o A manual inspection of the incision site should occur, along with inspection of the surrounding surgical … Education should occur upon hire, annually, and when this protocol is added to job responsibilities.2 … performing a failure mode and effects analysis to better understand the process and where breakdowns occur