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  1. www.ahrq.gov/research/findings/final-reports/stpra/stpra2.html
    April 01, 2018 - Is proactive, identifying the possible adverse events before they actually occur, thus enabling the decision … major limitation of isolated database analyses in which the interactions of different-level processes occur … of ambulatory procedures, they are constrained in that complications, particularly infections that occur … Each site visit represented a different context in which SSIs can occur within the ambulatory surgery … a useful method for incorporating the data gathered from the site visits, because contamination can occur
  2. www.ahrq.gov/patient-safety/settings/hospital/candor/modules/checklist5.html
    August 01, 2022 - tool: Use Part I of the checklist to prepare for the initial disclosure conversation, which should occur
  3. 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?
  4. www.ahrq.gov/patient-safety/reports/issue-briefs/dxchecklists-5.html
    September 01, 2020 - These errors occur when the plan of an action was incorrect (e.g., due to lack of knowledge).
  5. www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxchecklists-5.html
    September 01, 2020 - These errors occur when the plan of an action was incorrect (e.g., due to lack of knowledge).
  6. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Kizer2.pdf
    December 01, 2000 - Identifying where and when in the care process mishaps occur, and changing processes of care to reduce … and the NQF formally endorsed a list of Serious Reportable Events in health care that should never occur—what … Many rare, but serious, events are cause for considerable concern when they occur. … reportable events that should be reported and investigated by all health care facilities if they occur … Excludes emergent situations that occur in the course of surgery and/or whose exigency precludes obtaining
  7. www.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
  8. www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/handouts/patient-chg-bathing.pdf
    March 01, 2022 - Your Hospital Stay BATHE Daily With Chlorhexidine (CHG) Cloths During your stay, bathing will occur
  9. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-surgery/139-sample-completed-staff-safety-assessment.docx
    April 01, 2025 - · Establish that hair removal should only occur immediately before a patient is taken to the OR. · Remove
  10. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/139-sample-completed-staff-safety-assessment.docx
    April 01, 2025 - · Establish that hair removal should only occur immediately before a patient is taken to the OR. · Remove
  11. www.ahrq.gov/patient-safety/resources/simulation-issue-brief3.html
    July 01, 2024 - Over time, as the benefits of simulation gain appreciation, fewer cancellations may occur. 16,17 Simulation
  12. www.ahrq.gov/antibiotic-use/long-term-care/four-moments/index.html
    August 01, 2021 - Four Moments of Antibiotic Decision Making The Four Moments of Antibiotic Decision Making are the critical time periods of antibiotic decision making. Frontline staff and prescribing clinicians are encouraged to use the Four Moments framework for all residents whenever the need for antibiotics is being c…
  13. www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/factraining.html
    November 01, 2017 - Communicate risk changes as they occur. … Improve root cause analyses when adverse events occur. … When would the meeting occur? … How would communication occur with other disciplines to confirm changes in care? … When would the meeting occur?
  14. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/mcaidread_tool1_data_analysis_final.xlsx
    September 20, 2016 - Topic 2: Readmissions by Payer How many readmissions occur at your hospital every year? … What you are looking for: Typically, 25% of readmissions occur within 4 days and 50% of readmissions … occur within 10 days of discharge. … How many readmissions occur at your hospital every year? … occur within 10 days of discharge.
  15. www.ahrq.gov/research/findings/final-reports/ptfamilyscan/ptfamily1.html
    July 01, 2018 - patient and family engagement, the explication of a conceptual framework for how engagement is likely to occur … All these elements occur within an external environmental context that includes resources, constraints
  16. www.ahrq.gov/es/patient-safety/settings/hospital/resource/nicu/packet/apb.html
    December 01, 2013 - UTI and urolithiasis do not occur any more frequently than in general population. … If the ductus is open at the time of hospital discharge, followup with a cardiologist should occur within … 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
  17. www.ahrq.gov/patient-safety/settings/hospital/resource/nicu/packet/apb.html
    December 01, 2013 - UTI and urolithiasis do not occur any more frequently than in general population. … If the ductus is open at the time of hospital discharge, followup with a cardiologist should occur within … 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
  18. 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
  19. Section 5, Table 3 (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-229-section-5-table-3.pdf
    August 01, 2014 - Because rapid sterilization of blood cultures can occur within a few hours after the first antimicrobial … Sampling before antibiotic therapy is important, because sterilization of blood cultures can occur
  20. www.ahrq.gov/cahps/surveys-guidance/item-sets/cg/suppl-carespecialists-cg30-adult.html
    December 01, 2018 - Some items cover events that occur with low frequency in the general population.

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