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1. Module 1: An Overview of the CANDOR Process | Agency for Healthcare Research and Quality
   teamstepps.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
   teamstepps.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. Human Factors in Surgery: Shifting the Paradigm on Patient Safety | Agency for Healthcare Research and Quality
   teamstepps.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

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

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

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

7. AHRQ Tribal Consultation Policy | Agency for Healthcare Research and Quality
   teamstepps.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

8. Module 6: Care for the Caregiver | Agency for Healthcare Research and Quality
   teamstepps.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

9. Four Moments of Antibiotic Decision Making | Agency for Healthcare Research and Quality
   teamstepps.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.

10. Selected Best Practices and Suggestions for Improvement (pdf file)
    teamstepps.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

11. Selected Best Practices and Suggestions for Improvement (pdf file)
    teamstepps.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

12. Pressure Ulcer Prevention Toolkit (doc file)
    teamstepps.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

13. TeamSTEPPS Fundamentals Course: Module 4. Leading Teams | Agency for Healthcare Research and Quality
    teamstepps.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

14. Module 4: Event Reporting, Event Investigation and Analysis | Agency for Healthcare Research and Quality
    teamstepps.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes4.html
    August 01, 2022 - Within the first 72 hours of a CANDOR event, the following actions should occur: Schedule and complete

15. Four Moments of Antibiotic Decision Making | Agency for Healthcare Research and Quality
    teamstepps.ahrq.gov/antibiotic-use/long-term-care/four-moments/index.html
    August 01, 2021 - 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 …

16. Communication-Facilitator-Guide (doc file)
    teamstepps.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/communication-facilitator-guide.docx
    June 01, 2021 - This can occur after someone has had antibiotics and can be devastating in nursing home residents. … 13 Case 3: Communication SAY: Let’s walk through a final case of communication errors that can occur … The nurse does not feel comfortable with this plan and knows that serious side effects can occur on antibiotics … Slide 16 Case 3 — DESC Script SAY: Conflict can occur in teams, and it is important to know how … to handle such situations when they occur.

17. How To Implement the Pressure Injury Prevention Program in Your Organization
    teamstepps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module4/module4_pu-implementation_slides.pptx
    November 20, 2014 - Unit staff tell the Wound Care Team about high-risk patients or if skin problems occur. … 19 Practice Insight Staff Turnover 20 Communication Patterns Good communication needs to occur

18. Mod5-Disclosure-Checklist (pdf file)
    teamstepps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/mod5-disclosure-checklist.pdf
    April 01, 2016 - tool: Use Part I of the checklist to prepare for the initial disclosure conversation, which should occur

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

20. Strategy 2: Communicating for Improve Quality (Tool 1) (doc file)
    teamstepps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy2/Strat2_Tool_1_Be_Partner_508.docx
    February 10, 2011 - Nurse shift changes occur when nurses who are going off duty share information about you with nurses