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41. Pressure Ulcer Prevention Toolkit (doc file)
    pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module4/putoolkit_module4_tools.docx
    January 01, 1995 - Friction may occur when moving a person up in bed. 43. … For persons who have incontinence, skin cleaning should occur at the time of soiling and at routine intervals … Friction may occur when moving a person up in bed. True 43. … For persons who have incontinence, skin cleaning should occur at the time of soiling and at routine intervals

42. FileNewTemplate
    pbrn.ahrq.gov/sites/default/files/wysiwyg/teamstepps/officebasedcare/ts-obc-online-module11.pptx
    March 07, 2019 - So, look at those things that occur frequently. … When and where will the improvements occur? … The outcome aims should focus on changes that occur because your staff carries out the interventions … Write down the process steps as they currently occur, and identify who’s doing what, when, with what … When will the training sessions occur and for how long? Where will the sessions occur?

43. Mod01-Grand-Rounds-Slides (pdf file)
    pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/grandrounds/mod01-grand-rounds-slides.pdf
    April 01, 2016 - Slide 39 Say: Resolution can truly occur only after the organization has completed its investigation

44. Reducing Workplace Violence with TeamSTEPPS® | Agency for Healthcare Research and Quality
    pbrn.ahrq.gov/teamstepps/events/webinars/dec-2016.html
    July 01, 2018 - Communication and Teamwork Slide 13: No Slide Title Slide 14: Team Structure Slide 15: Where May Violence Occur … Return to Contents   Slide 15 Where May Violence Occur? … Violence may occur anywhere in the health care facility, but it is most frequent in the following areas

45. Diagnostic Safety and Quality | Agency for Healthcare Research and Quality
    pbrn.ahrq.gov/diagnostic-safety/index.html
    January 01, 2007 - Diagnostic errors occur in all settings of care, contribute to about 10 percent of patient deaths, and

46. Concept: Conflict in Teams | Agency for Healthcare Research and Quality
    pbrn.ahrq.gov/teamstepps-program/curriculum/mutual/tools/conflict.html
    July 01, 2023 - Concept: Conflict in Teams It is important to acknowledge that conflict can occur

47. TeamSTEPPS Video Debrief Guide: Huddle in Emergency Department (pdf file)
    pbrn.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/video/huddle-emergency-dept-guide.pdf
    August 31, 2023 - In the huddle, the team anticipates problems that may occur and makes plans for them: • The patient

48. PowerPoint Presentation
    pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/grand-rounds-presentation-slides.pptx
    January 01, 2014 - Many different forms, by different people, occur over time: Explanation of event’s cause and prevention … organization leaders in approaching these difficult discussions. 40 Module 1 Resolution can truly occur

49. Module 7: Resolution | Agency for Healthcare Research and Quality
    pbrn.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

50. System-Focused Event Investigation and Analysis Guide | Agency for Healthcare Research and Quality
    pbrn.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

51. Tool 1: Readmission Data Analysis and Interpretation (xls file)
    pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/mcaidread_tool1_data_analysis_final.xlsx
    September 20, 2016 - Topic 2: Readmissions by Payer How many readmissions occur at your hospital every year? … What you are looking for: Typically, 25% of readmissions occur within 4 days and 50% of readmissions … occur within 10 days of discharge. … How many readmissions occur at your hospital every year? … occur within 10 days of discharge.

52. AHRQ Comment Policy | Agency for Healthcare Research and Quality
    pbrn.ahrq.gov/policy/social-media/comments/index.html
    August 01, 2018 - Comment and content review and posting will generally occur during regular business hours from Monday

53. Overview | Agency for Healthcare Research and Quality
    pbrn.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/overview.html
    January 01, 2013 - & Medicaid Services (CMS) does not reimburse hospitals for certain types of traumatic injuries that occur … while a patient is in the hospital iv ; many of these injuries could occur after a fall. … This toolkit focuses specifically on reducing falls that occur during a patient's hospital stay.

54. Module 5: Response and Disclosure | Agency for Healthcare Research and Quality
    pbrn.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

55. The How-To’s of Hand Hygiene | Agency for Healthcare Research and Quality
    pbrn.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.

56. TeamSTEPPS Fundamentals Course: Module 2. Team Structure | Agency for Healthcare Research and Quality
    pbrn.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? 

57. Describe How a Plan or Provider Can Influence a Quality Measure | Agency for Healthcare Research and Quality
    pbrn.ahrq.gov/talkingquality/translate/labels/describe.html
    January 01, 2023 - The highest percentage of pressure ulcers occur in our intensive care areas where our patients have complex

58. Disclosure Checklist | Agency for Healthcare Research and Quality
    pbrn.ahrq.gov/patient-safety/settings/hospital/candor/modules/checklist5.html
    August 01, 2022 - tool: Use Part I of the checklist to prepare for the initial disclosure conversation, which should occur

59. Saving Lives and Saving Money: Hospital-Acquired Conditions Update | Agency for Healthcare Research and Quality
    pbrn.ahrq.gov/hai/pfp/2014-final.html
    January 01, 2018 - SHARE: More topics in this section Healthcare-Associated Infections Program Combating Antibiotic-Resistant Bacteria About the CUSP Method Decolonization – Universal and Targeted Tools Saving Lives and Saving Money: Hospi…

60. CAHPS Supplemental Items | Agency for Healthcare Research and Quality
    pbrn.ahrq.gov/cahps/surveys-guidance/item-sets/search.html
    April 29, 2024 - Note: Some items cover events that occur with low frequency in the general population.