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

3. newbref
   talkingquality.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?

4. Human Factors in Surgery: Shifting the Paradigm on Patient Safety | Agency for Healthcare Research and Quality
   talkingquality.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. 6 Tk1 T2-Talking With Residents Family Members Checklist Version Final (pdf file)
   talkingquality.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

6. Adverse Drug Events Occurring in U.S. Hospitals | Agency for Healthcare Research and Quality
   talkingquality.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 …

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

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

9. AHRQ Tribal Consultation Policy | Agency for Healthcare Research and Quality
   talkingquality.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

10. AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Electronic Fetal Monitoring (doc file)
    talkingquality.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

11. Module 6: Care for the Caregiver | Agency for Healthcare Research and Quality
    talkingquality.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

12. Four Moments of Antibiotic Decision Making | Agency for Healthcare Research and Quality
    talkingquality.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.

13. Selected Best Practices and Suggestions for Improvement (pdf file)
    talkingquality.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

14. Selected Best Practices and Suggestions for Improvement (pdf file)
    talkingquality.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

15. Grand Rounds Presentation | Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/patient-safety/settings/hospital/candor/grand-rounds.html
    August 01, 2022 - Slide 39 Say: Resolution can truly occur only after the organization has completed its investigation

16. Morningbriefing (doc file)
    talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/morningbriefing.doc
    August 07, 2012 - physicians and nurses identify the problems that occurred during the night and potential problems that may occur

17. Pressure Ulcer Prevention Toolkit (doc file)
    talkingquality.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

18. Mod01-Grand-Rounds-Slides (pdf file)
    talkingquality.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

19. TeamSTEPPS Fundamentals Course: Module 4. Leading Teams | Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/teamstepps/instructor/fundamentals/module4/igleadership.html
    March 01, 2019 - 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

20. TeamSTEPPS Video Debrief Guide: Huddle in Emergency Department (pdf file)
    talkingquality.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