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  1. www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/cg/instructions/suppl-access_items_cg-cahps-adult-survey_2357-1a.docx
    June 02, 2025 - Some items cover events that occur with low frequency in the general population.
  2. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/023-ss-cusp-learning-from-defects-fg.docx
    April 01, 2025 - SAY: Defects are flaws, imperfections, or problems that occurred or could occur in the clinical or operational … A contributing factor that is a major reason but does not occur often offers a potential opportunity … Slide 25 Case Example Using the Investigating a Defect Worksheet: Why Did This Defect Occur?
  3. www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-reimagining-healthcare-teams-3.html
    July 01, 2023 - example, atrial fibrillation can be asymptomatic or symptomatic, can be chronic or paroxysmal, and can occur
  4. www.ahrq.gov/sites/default/files/2024-02/berry-report.pdf
    January 01, 2024 - Incomplete regimens may occur in over half of instances (Clin Infect Dis 2012). … Rebound and development of resistance often occur by 7 to 14 days (AIDS 2008). … Post-discharge outpatient HIV follow-up visits occur about 2/3 of the time but typically occur 7 to 14 … Thus, adverse effects are likely to occur before an outpatient HIV provider can correct the error. … HCV viral rebound may occur quickly.
  5. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4n_combo_iqi-mortalityreview-bestpractices.pdf
    May 20, 2016 - community and the public on the estimation that between 48,000 and 98,000 deaths from medical errors occur …  Yes:  Did any of the following occur during hospitalization? …  Yes:  Did any of the following occur during the hospitalization (check all that apply) ∗ Death
  6. www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-dx-stewardship4.html
    August 01, 2024 - These errors can occur through inappropriate or inadequate quality control procedures, atypical characteristics
  7. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/educational-bundles/infection-prevention/hand-hygiene/hand-hygiene.pptx
    March 01, 2017 - CAUTIs. 2 Health Care Workers’ Hands Spread Infections1 1-3 million serious infections estimated to occur … remember these four times for hand hygiene during your care of residents, including interactions that occur … Hand contamination may occur as a result of small undetected holes in gloves Hand contamination may occur
  8. www.ahrq.gov/news/newsroom/press-releases/nac-meeting-june28-29.html
    June 01, 2024 - The meeting will occur at the Hilton Baltimore Inner Harbor, 401 W. Pratt St., Baltimore, MD 21201.
  9. www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/four-moments-explained.pdf
    June 01, 2021 - Four Moments of Antibiotic Decision Making Explained Moment 1 occurs when a resident is assessed for a change in status and there is a concern for infection. Sometimes long-term care staff recognize that something is not quite right with the resident but aren’t clear on what is wrong. The person doing the assessmen…
  10. www.ahrq.gov/patient-safety/reports/engage/warmhandoff.html
    April 01, 2018 - A Warm Handoff Plus can occur between any two members of the healthcare team, including clinicians, medical
  11. www.ahrq.gov/sites/default/files/wysiwyg/research/publications/pubcomguide/Location-Release-fillable-form.pdf
    April 01, 2024 - hold the Administrator harmless from, and indemnify against, any injury to any person(s) that may occur
  12. www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/resources/issue-briefs/dxsafety-cognitive-load-theory.pdf
    May 01, 2024 - being given to cognitive load theory (CLT), an educational model for how human memory and processing occur … When you consider all the cognitive processes that must occur with reasonable precision during the diagnostic … 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
  13. www.ahrq.gov/news/newsletters/e-newsletter/908.html
    April 01, 2024 - Surge in Drug Shortages Occurred in Wake of Pandemic, Study Finds Issue Number 908 AHRQ News Now is a weekly newsletter that highlights agency research and program activities. April 9, 2024 AHRQ Stats: Trends in Psychological Distress During the COVID-19 Pandemic Between 2018 and 2021, the proportion …
  14. www.ahrq.gov/sites/default/files/2024-01/bolton-report.pdf
    January 01, 2024 - Methods: In this research, we use automated proof techniques to determine if masking can occur in a … 17,25,29,31,32 and instances of it have been detected experimentally.30,37 However, masking may only occur … of the represented alarms along with the specification properties for checking whether masking can occur … This is because total masking can occur in the presence of three or fewer alarms, and partial masking … A ∅ indicates that no masking could occur.
  15. www.ahrq.gov/sites/default/files/2024-02/hoff-report.pdf
    January 01, 2024 - contextual features of the work environment appeared to undermine the opportunity for best practices to occur … To determine which best practices could be expected to occur around a given error or near miss, we considered … Only in the MICU did resident responses that led to group best practices occur with greater frequency … These types of responses short-circuited the prospects for practices such as self-reflection to occur … an approach produces a heightened probability that at least some of the desired culture change will occur
  16. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/resources/tools/improve/discussion-guide.docx
    March 01, 2017 - Whichever template you choose, you should document the following: · What actions or changes will occur … · By when will the actions and changes occur?
  17. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallspximplsteps.pdf
    June 02, 2025 - Monthly After about 6 months, the Facilitator’s role is to check in to identify obstacles that could occur … The expectation is that reports will be used on a weekly basis except for meetings that occur less frequently
  18. Puh-Impsteps (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-impsteps.docx
    June 02, 2025 - Monthly After about 6 months, the facilitator’s role is to check in to identify obstacles that could occur … The expectation is that reports will be used on a weekly basis except for meetings that occur less frequently
  19. www.ahrq.gov/teamstepps-program/curriculum/implement/pre-measure.html
    May 01, 2023 - implementation; how long after the training were you expecting the changes in processes and outcomes to occur
  20. www.ahrq.gov/teamstepps-program/curriculum/communication/tools/checkback.html
    July 01, 2023 - patient harm are often caused by a provider overlooking messages alerting them to a test result or occur

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