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1. Adverse Drug Events occurring in U.S. Hospitals (pdf file)
   pcmh.ahrq.gov/sites/default/files/wysiwyg/data/infographics/adverse-drug-events.pdf
   July 02, 2015 - Hospitals Adverse drug events (ADEs) are the most common nonsurgical adverse events that occur in hospitals

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

3. Action Planning Worksheets | Agency for Healthcare Research and Quality
   pcmh.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?  

4. Human Factors in Surgery: Shifting the Paradigm on Patient Safety | Agency for Healthcare Research and Quality
   pcmh.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

5. Four Moments of Antibiotic Decision Making | Agency for Healthcare Research and Quality
   pcmh.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.

6. Implementation Guide for the CANDOR Process | Agency for Healthcare Research and Quality
   pcmh.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

7. Using Patient Input to Improve Diagnostic Safety | Agency for Healthcare Research and Quality
   pcmh.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

8. Advancing Diagnostic Safety: An AHRQ Leadership Conversation | Agency for Healthcare Research and Quality
   pcmh.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

9. Quick Reference Guide to TeamSTEPPS Action Planning | Agency for Healthcare Research and Quality
   pcmh.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

10. Adverse Drug Events Occurring in U.S. Hospitals | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/data/infographics/adverse-drug-events.html
    August 01, 2018 - SHARE: More topics in this section Data & Analytics Data Infographics Data Visualizations Data Tools Data Innovations All-Payer Claims Databases Healthcare Cost and Utilization Project (HCUP) Medical Expenditure Panel Survey…

11. Job Aid: Process Mapping (pdf file)
    pcmh.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/job-aid-process-mapping.pdf
    May 17, 2021 - specific actions of different individuals (or departments) in the process and the places where handoffs occur … Remind participants to use appropriate symbols, stack actions that occur at same time, and reevaluate

12. Scisafetynotes (doc file)
    pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/understand/scisafetynotes.docx
    September 04, 2012 - Slide 4 SAY: Errors occur within the health care setting because people are fallible. … 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.

13. newbref
    pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module11/m11impguide.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?

14. AHRQ Tribal Consultation Policy | Agency for Healthcare Research and Quality
    pcmh.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

15. The Quick Reference Guide to TeamSTEPPS Action Planning | Agency for Healthcare Research and Quality
    pcmh.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. 6 Tk1 T2-Talking With Residents Family Members Checklist Version Final (pdf file)
    pcmh.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

17. TeamSTEPPS 2.0 Quick Reference Guide to TeamSTEPPS Action Planning (pdf file)
    pcmh.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

18. Surge in Drug Shortages Occurred in Wake of Pandemic, Study Finds | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/news/newsletters/e-newsletter/908.html
    April 01, 2024 - SHARE: More topics in this section News Newsroom Blog Newsletter AHRQ News Now Events Surge in Drug Shortages Occurred in Wake of Pandemic, Study Finds Issue Number 908 AHRQ News Now is a weekly new…

19. Module 6: Care for the Caregiver | Agency for Healthcare Research and Quality
    pcmh.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

20. TeamSTEPPS Implementation Guide | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/teamstepps/instructor/essentials/implguide.html
    November 01, 2018 - Key Actions: Multiple actions occur during Phase I to assess organizational readiness for a TeamSTEPPS … Where will it occur? What do we hope to achieve with a TeamSTEPPS Intervention? … Key Actions: Three key actions occur during Phase II — writing a TeamSTEPPS Action Plan, conducting … TeamSTEPPS Action Plan written during Phase II provides the "how-to" guidelines for the key actions that occur … targeted problem or opportunity for improvement occurs – write down the process steps as they currently occur