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21. Introduction | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/distributed-cognition-er-nurses1.html
    August 01, 2022 - References Each year, approximately 141 million emergency department (ED) visits occur

22. Development and Validation of the Medication Administration Error Reporting Survey (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Wakefield2.pdf
    January 01, 2003 - Five subscales emerged for “reasons why MAE occur”; four subscales emerged for “reasons why MAE are … medication administration errors occur. … Reasons why medication errors occur (19 items in 1994 and 29 in subsequent surveys). 2. … In the first content area, “why MAEs occur,” five factors emerged. … Nurses’ perceptions of why medication administration errors occur.

23. On-Time Pressure Ulcer Healing: Facilitator Training Slide Presentation | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/facslides.html
    December 01, 2017 - Nursing homes investigate adverse events after they occur. … Is it possible to intervene before adverse events occur? … Communication: Reviews existing team meetings/huddles that occur at the facility. … When will the meeting occur? Which report(s) will be used at the meeting? … How will communication occur with other disciplines to confirm changes in care?

24. AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention Facilitator Training | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/factraining-slides.html
    October 01, 2017 - Nursing homes investigate adverse events after they occur. … Is it possible to intervene before adverse events occur? … Analysis: Reviews process for conducting investigations or root cause analyses when adverse events occur … When will the meeting occur? Which reports will be used at the meeting? … How will communication occur with other disciplines to confirm changes in care?

25. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/facslides.html
    September 01, 2017 - Nursing homes investigate adverse events after they occur. … Is it possible to intervene before adverse events occur? … Communication: Reviews existing team meetings/huddles that occur at the facility. … When will the meeting occur? Which reports will be used at the meeting? … How will communication occur with other disciplines to confirm changes in care?

26. PowerPoint Presentation
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/fallpxoverview.pptx
    October 01, 2017 - Nursing homes investigate adverse events after they occur. … Is it possible to intervene before adverse events occur? … Analysis: Reviews process for conducting investigations or root cause analyses when adverse events occur … When will the meeting occur? Which reports will be used at the meeting? … How will communication occur with other disciplines to confirm changes in care?

27. PowerPoint Presentation
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-factraining-slides.pptx
    November 01, 2016 - Nursing homes investigate adverse events after they occur. … Is it possible to intervene before adverse events occur? … Analysis: Reviews process for conducting investigations or root cause analyses when adverse events occur … When will the meeting occur? Which report(s) will be used at the meeting? … How will communication occur with other disciplines to confirm changes in care?

28. Pocket Cards_4 Moments (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/four-moments/poster-three-options.pdf
    November 01, 2019 - Moment 4 should occur as soon as it is clear what infectious process is being treated and the patient … Moment 4 should occur as soon as it is clear what infectious process is being treated and the patient

29. Additional Benefits of Simulation | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/resources/simulation-issue-brief6.html
    July 01, 2024 - consisting of short discussions immediately after a clinical event, or “cold,” consisting of reviews that occur

30. AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/slides.html
    December 01, 2014 - Nursing homes investigate adverse events after they occur. … Is it possible to intervene before adverse events occur? … Communication: Reviews existing team meetings/huddles that occur at the facility. … When will the meeting occur? Which report(s) will be used at the meeting? … How will communication occur with other disciplines to confirm changes in care?

31. PowerPoint Presentation
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruprev/factraining_slides.pptx
    December 01, 2014 - Nursing homes investigate adverse events after they occur. … Is it possible to intervene before adverse events occur? … Analysis: Reviews process for conducting investigations or root cause analyses when adverse events occur … When will the meeting occur? Which report(s) will be used at the meeting? … How will communication occur with other disciplines to confirm changes in care?

32. PowerPoint Presentation
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/ontime-preventablehospitaledvisits-overview.pptx
    May 01, 2017 - Nursing homes investigate adverse events after they occur. … Is it possible to intervene before adverse events occur? … Analysis: Reviews process for conducting investigations or root cause analyses when adverse events occur … When will the meeting occur? Which reports will be used at the meeting? … How will communication occur with other disciplines to confirm changes in care?

33. FAQs (Staff): Safety and Side Effects: CHG and Mupirocin (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/faqs/faq-safety-chg-mupirocin.docx
    March 01, 2022 - However, as with any product, side effects may occur. … Local CHG side effects are estimated to occur in 1–3 percent of patients.

34. Equipment and Supplies | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/shuttered/toolkitchecklist/surgetkit3.html
    July 01, 2018 - Timeframe: The operations activities listed below will occur between opening day and until the facility … The steps listed below must occur for this process to be successful. … will be transported within the first few days, but continued patient transport to the facility might occur … Also, termination of on-going contracts or arrangements must occur. … determined that the surge facility is no longer needed, all patient transport out of the facility should occur

35. Scisafetynotes (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/understand/scisafetynotes.docx
    June 02, 2025 - 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.

36. Supplemental Items for the CAHPS Clinician & Group Adult Survey: Communication Barriers | Agency for Healthcare Research and Quality
    www.ahrq.gov/cahps/surveys-guidance/item-sets/cg/suppl-communication-barriers-cg30-adult.html
    December 01, 2023 - Some items cover events that occur with low frequency in the general population.

37. Addressing Questions Asked by Staff: Safety and Side Effects of Chlorhexidine and Mupirocin (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/faqs/faq-safety-chg-mupirocin.pdf
    March 01, 2022 - However, as with any product, side effects may occur. … Local CHG side effects are estimated to occur in 1–3 percent of patients.

38. T.E.A.M.S. infographic | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/resources/tools/improve/teams-infographic.html
    March 01, 2017 - Culture influences how change can occur.

39. 047-Ss-Faqs-Staff-Safety-Side-Effects (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/047-ss-faqs-staff-safety-side-effects.docx
    April 01, 2025 - Local CHG side effects are estimated to occur in 1–3 percent of patients. … For example, this may occur if CHG enters the ear canal of patient with a perforated ear drum.

40. Understand the Science of Safety for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/understand-sci-fac-guide.html
    July 01, 2023 - Say: Errors occur within the health care setting because health care professionals are human, and humans … 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.