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  1. www.ahrq.gov/topics/medical-errors.html
    Topic: Medical Errors Medical errors can occur anywhere in the health care system--in hospitals, clinics
  2. www.ahrq.gov/topics/stroke.html
    "Mini-strokes" or transient ischemic attacks (TIAs), occur when the blood supply to the brain is briefly
  3. www.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
  4. www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit3-5.html
    November 01, 2014 - Wave 2 of Lean training and projects occur. Trainings conducted by external consultant. … Wave 4 of Lean training and projects occur. … Wave 5 of Lean training and projects occur. … X X             Wave 4 of Lean training and projects occur. … X X         Wave 5 of Lean training and projects occur.
  5. www.ahrq.gov/patient-safety/settings/hospital/match/appendix/app-5.html
    July 01, 2022 - When does reconciliation occur? … When does the followup occur? … When does the followup occur? … When does this occur? … When does the followup occur?
  6. www.ahrq.gov/es/patient-safety/settings/hospital/match/appendix/app-5.html
    July 01, 2022 - When does reconciliation occur? … When does the followup occur? … When does the followup occur? … When does this occur? … When does the followup occur?
  7. www.ahrq.gov/topics/healthcare-associated-infections-hais.html
    May 12, 2015 - Over a million HAIs occur across the U.S. health care system every year, leading to the loss of tens
  8. www.ahrq.gov/patient-safety/resources/match/matchap5.html
    August 01, 2012 - When does reconciliation occur? … When does the followup occur? … When does the followup occur? … When does this occur? … When does the followup occur?
  9. www.ahrq.gov/hai/universal-icu-decolonization/universal-icu-apg.html
    September 01, 2013 - In rare case reports, anaphylaxis can occur (difficulty breathing; tightness in the chest; swelling of … For example, this may occur if CHG enters the ear canal and the patient has a perforated (punctured)
  10. www.ahrq.gov/sites/default/files/wysiwyg/opioids/compendium/opioids-compendium-self-assessment.pdf
    December 01, 2023 - …occur infrequently. …occur regularly but rarely impact care planning. … …occur regularly and result in changes to care plans and chronic pain management. … …occur infrequently. …occur regularly but rarely impact care planning. … …occur regularly and result in changes to care plans and chronic pain management. … …occur infrequently. …occur regularly but do not impact care planning.
  11. www.ahrq.gov/es/hai/universal-icu-decolonization/universal-icu-apg.html
    September 01, 2013 - In rare case reports, anaphylaxis can occur (difficulty breathing; tightness in the chest; swelling of … For example, this may occur if CHG enters the ear canal and the patient has a perforated (punctured)
  12. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-pda.pdf
    December 13, 2013 - ■ If the ductus is open at the time of hospital discharge, followup with a cardiologist should occur … – Earlier followup should occur if poor weight gain, difficulty feeding, and tachypnea develop. … Management ■ If spontaneous closure does not occur, closure should be performed to: – Eliminate pulmonary
  13. www.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.
  14. www.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?  
  15. www.ahrq.gov/questions/resources/20-tips.html
    November 01, 2020 - 20 Tips To Help Prevent Medical Errors: Patient Fact Sheet Medical errors can occur … But medical errors can occur anywhere in the health care system: In hospitals, clinics, surgery centers … What do I do if they occur?
  16. www.ahrq.gov/teamstepps/officebasedcare/impworkbook.html
    December 01, 2015 - 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?    
  17. www.ahrq.gov/funding/grantee-profiles/grtprofile-rinke.html
    December 01, 2019 - Rinke’s research revealed that CLABSIs occur three times more frequently in ambulatory settings than … funding to conduct multisite epidemiological studies focused on healthcare-associated infections that occur … Preliminary data suggest that CLABSIs occur at comparable rates in inpatient and ambulatory settings. … He found that diagnostic errors and missed opportunities for diagnosis occur often in pediatric primary
  18. www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-cognitive-load3.html
    May 01, 2024 - process information, and execute performance-based tasks effectively. 11 Although cognitive overload can occur … information overload, multitasking and interruptions, and environmental threats. 20 Information overload can occur … If clinicians cannot selectively engage with interruptions, cognitive overload will occur if too much … If extrinsic load is low, both type 1 and type 2 thinking can occur. … Conversely, if extrinsic load increases, as can occur with a chaotic environment, distractions, unsafe
  19. www.ahrq.gov/patient-safety/reports/issue-briefs/maternal-mortality-1.html
    September 01, 2021 - 700 birthing people dying every year from pregnancy-related causes. 7 One-third of maternal deaths occur … The brief focuses on the maternal events that occur during childbirth and up to a week postpartum, with
  20. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/module1-overview.pptx
    May 19, 2016 - 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 3rd and 4th components should occur simultaneously. … Let’s examine the specific activities that occur during the 4th component of the CANDOR process, Event … 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.

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