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1. Medical Errors | Agency for Healthcare Research and Quality
   www.ahrq.gov/topics/medical-errors.html
   Topic: Medical Errors Medical errors can occur anywhere in the health care system--in hospitals, clinics

2. Adverse Drug Events occurring in U.S. Hospitals (pdf file)
   www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/adverse-drug-events.pdf
   June 02, 2025 - Hospitals Adverse drug events (ADEs) are the most common nonsurgical adverse events that occur in hospitals

3. Healthcare-Associated Infections (HAIs) | Agency for Healthcare Research and Quality
   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

4. Exhibit 3.5. Chronology of Quality Improvement and Lean at the Parent Organization and Academic Medical Center | Agency for Healthcare Research and Quality
   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. Appendix, Develop a Flowchart of Your Current Medication Reconciliation Process | Agency for Healthcare Research and Quality
   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. Appendix, Develop a Flowchart of Your Current Medication Reconciliation Process | Agency for Healthcare Research and Quality
   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. Appendix G. Safety and Adverse Events | Agency for Healthcare Research and Quality
   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)

8. NICU Family Information Packet, Appendix B, Patent Ductus Arteriosus (pdf file)
   www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-pda.pdf
   June 02, 2025 - ■ 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

9. Appendix G. Safety and Adverse Events | Agency for Healthcare Research and Quality
   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)

10. Practice Self-Assessment Tool for Opioid Use in Older Adults (pdf file)
    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. Module 1: An Overview of the CANDOR Process | Agency for Healthcare Research and Quality
    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.

12. Module 1: Communication and Optimal Resolution (CANDOR) Toolkit Module 1: An Overview of the CANDOR Process
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/module1-overview.pptx
    June 02, 2025 - 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.

13. Patient, Family Member, and Clinician Perceptions of Disclosure of Adverse Events in Labor and Delivery | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/reports/liability/baker.html
    August 01, 2017 - families in the care team and how to communicate with patients about the risks and mistakes that can occur … kinds of information should be disclosed regarding each event and explore how communication should occur … Second, we wanted to ascertain how patient and family and provider communication should occur to mitigate … Last, we interviewed 12 clinicians about the common failures that can occur leading to each event. … The highest level of agreement was for those failures that could occur during the Delivery phase for

14. 066-Dec-Staff-Faqs-Safety-Side-Effects (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/066-dec-staff-faqs-safety-side-effects.docx
    October 01, 2024 - However, as with any product, side effects may occur. … Local CHG side effects are rare, estimated to occur in 1% to 3% of patients. … For example, this may occur if CHG enters the ear canal, and the patient has a perforated (punctured)

15. Interplay Between Cognitive Load and Diagnostic Accuracy | Agency for Healthcare Research and Quality
    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

16. Learn From Defects in Care of Mechanically Ventilated Patients: Slide Presentation | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/mvp/modules/cusp/learn-from-defects-slides.html
    February 01, 2017 - List contributing factors that make defects in care more likely to occur. … Why 1—Why did this contributing factor occur? Why 2—Why did “Why 1” occur? … Why 3—Why did “Why 2” occur? Why 4—Why did “Why 3” occur? Why 5—Why did “Why 4” occur? … Does it occur rarely or have a high likelihood of reoccurring?

17. Presentation: Program Overview
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/learn-from-defects-slides.pptx
    January 01, 2017 - and second-order problem solving List contributing factors that make defects in care more likely to occur … you identify contributing factors Use the “5 Whys” technique Why 1—Why did this contributing factor occur … Why 2—Why did “Why 1” occur? Why 3—Why did “Why 2” occur? Why 4—Why did “Why 3” occur? … Why 5—Why did “Why 4” occur? … Does it occur rarely or have a high likelihood of reoccurring?

18. Playbook for Preventing CLABSI and CAUTI in the ICU Setting | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/clabsi-cauti-icu/implement/playbook.html
    February 01, 2025 - CUSP can be implemented through CLABSI and CAUTI prevention practices, policies, and procedures that occur

19. Acute Care Asymptomatic Bacteriuria and Urinary Tract Infections
    www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/allergies-slides.pptx
    September 01, 2022 - testing or evidence of hemolysis (jaundice, dark urine) or thrombocytopenia (petechiae) Most commonly occur … Serum sickness Vasculitis Palpable purpura Joint pain Urticaria Lymphadenopathy Fevers Most commonly occur … Ambulatory Care Allergy History: Timing3,12 How long after starting the antibiotic did the reaction occur … Type 1 allergies occur after the first or second dose Other types usually occur days later How long … ago did the reaction occur?

20. Conclusion | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/distributed-cognition-er-nurses5.html
    August 01, 2022 - Thus, it is no wonder that diagnostic errors occur.