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  1. www.ahrq.gov/research/findings/final-reports/stpra/stpraapc.html
    April 01, 2018 - If an infection were to occur, which surgeries carry the greatest consequence for the patient (e.g., … When does the surgical briefing occur? … Did a surgical site infection occur? How could this have been prevented? … Probe: : When postoperative SSIs occur, are they reported to ASC?
  2. www.ahrq.gov/hai/pfp/hacrate2013.html
    January 01, 2018 - 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013 Next Page Table of Contents 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013 Appendix References Summary …
  3. www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/patfamilyengagement/CUSP_Patient_Family_Engagement_Facilitator_Notes.docx
    June 02, 2025 - consider: · Planning and design · Everyday care · After an adverse event Slide 21 SAY: Adverse events occur … Rarely does an adverse event occur as a result of intent.
  4. www.ahrq.gov/research/publications/search.html?page=17
    October 01, 2011 - Number: 10-0058-EF 10 Patient Safety Tips for Hospitals Medical errors may occur
  5. www.ahrq.gov/hai/pfp/interimhacrate2013.html
    November 01, 2015 - Efforts To Improve Patient Safety Result in 1.3 Million Fewer Patient Harms Next Page Table of Contents Efforts To Improve Patient Safety Result in 1.3 Million Fewer Patient Harms Appendix References Interim Update on 2013 Annual Hospital-Acquired Condition Rate and Estimates of Co…
  6. Facilitator-Notes (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module4/facilitator-notes.docx
    March 01, 2017 - SLIDE 16 SAY: Handoffs occur during a change in assignment for the responsibility of caring for a … A handoff may occur when a resident is first welcomed to the nursing home from the hospital or during … another staff member, even for a short timespan such as a lunch break, a structured communication should occur
  7. www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/4.html
    December 01, 2017 - Static Week Calculation: Identify all weights that occur in the range of 85-95 days from the most … Static Week Calculation: Identify all weights that occur in the range of 170-190 days from the most
  8. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Banja.pdf
    January 01, 2004 - Situations occasionally occur in which a patient suffers significant medical complications that may … Reluctance to disclose preventable harms was twice as likely to occur at hospitals having major concerns … that the insurer will refuse to cover whatever associated costs, principally from a lawsuit, might occur … insured’s actions and intentions did not appear to be motivated by ethical obligation nor did they occur … illustrates that a truthful disclosure of what happened, in and by itself and especially as it might occur
  9. www.ahrq.gov/es/hai/universal-icu-decolonization/universal-icu-overvw.html
    September 01, 2013 - existing infrastructure for quality improvement (QI) by which QI and patient safety interventions usually occur
  10. www.ahrq.gov/news/newsroom/case-studies/ktcquips32.html
    October 01, 2014 - There was also a 13 percent improvement in their perceptions of whether problems occur during the exchange
  11. www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/resources/tools/engage/leader.html
    March 01, 2017 - Healthcare-associated infections (HAIs) occur far too often in nursing homes.
  12. www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/notes.html
    August 01, 2022 - not an isolated event, since there are many different points at which disclosure conversations can occur
  13. www.ahrq.gov/cahps/surveys-guidance/item-sets/cg/suppl-access-items-cg-survey30-adult.html
    December 01, 2018 - Some items cover events that occur with low frequency in the general population.
  14. www.ahrq.gov/cahps/surveys-guidance/item-sets/cg/suppl-access-items-cg-survey30-child.html
    December 01, 2018 - Some items cover events that occur with low frequency in the general population.
  15. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Duthie.pdf
    January 01, 2004 - Rare or unfamiliar circumstances compounded the potential that an adverse event would occur. … failure-to-rescue type events may help hospitals to undertake proactive steps so that, when an error does occur
  16. www.ahrq.gov/hai/tools/mvp/modules/cusp/learn-from-defects-fac-guide.html
    February 01, 2017 - second-order problem solving, list the contributing factors that make defects in care more likely to occur … Ask: Does the defect occur rarely or have a high likelihood of returning? … Say: Focus on a defect that carries the greatest risk of harm to the patients, is most likely to occur … As a general rule, consider factors that occur often as major reasons for the defect.
  17. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Comden.pdf
    January 01, 2003 - drug, wrong-dose, omitted-dose/drug, and wrong-patient medication errors) were modeled because they occur … wrong dose on order Q:0.001 Gate363 Read back occurs and fails Q:0.28 Event593 Read back does not occur … wrong dose on order Q:0.001 Gate363 Read back occurs and fails Q:0.28 Event593 Read back does not occur … These practices are generally forbidden in P&Ps, but this study found that they occur with some frequency … Too often, when adverse events occur, health care professionals lack the time and/or resources to thoroughly
  18. www.ahrq.gov/sites/default/files/2024-07/morse-merryweather-report.pdf
    January 01, 2024 - For high-fall-risk individuals, the largest number of CBs generally occur during the Stand Initiation … The highest number of CBs on average occur for those at high fall risk in every STSW phase when exiting
  19. www.ahrq.gov/practiceimprovement/delivery-initiative/ihs/chapter9.html
    December 01, 2017 - for addressing distributional issues related to the outcome variables and selection bias issues that occur
  20. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-McCabe_39.pdf
    March 28, 2008 - medications and referrals to specialists; (2) scheduling moves, which stipulate when future visits will occur … Current medication move The goal of this work was to predict whether an error of omission would occur … Circled numbers identify leaf nodes where errors are predicted to occur on the next visit. … Circled numbers identify leaf nodes where errors of omission are predicted to occur on the next visit … Rather, it predicts that an error is likely to occur at the next encounter.

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