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321. Developing an Effective Care Coordination System Implementation Guide
     www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/care-coordination-slides.pptx
     January 01, 2018 - Consider standardizing: Who is responsible for certain tasks When key activities will occur How specific … patient screening and who will follow up to make sure the patient has enrolled When key activities will occur … For example, specify when will the screening occur and when the conversation between the clinician … and patient/family will occur How specific activities will be performed For example, specify the

322. Improving Error Reporting in Ambulatory Pediatrics with a Team Approach (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Neuspiel_43.pdf
     March 05, 2008 - by resident physicians. 1 Limited information is available about the types of errors that occur … Since the vast majority of health care encounters with children occur on an outpatient basis, an understanding … Prior studies cited above suggest that medication errors alone may occur in 15 to 22 percent of outpatient

323. Lessons Learned from the Evolution of Mandatory Adverse Event Reporting Systems (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Flink.pdf
     April 09, 2004 - recommends that near misses also be included in reporting, as they represent most of the events that occur … NYPORTS allows analysis to occur at both the facility and NYSDOH levels for use in quality assurance … Analysis of NYPORTS data allows the NYSDOH and facilities to identify those areas where errors can occur … This is more likely to occur if key stakeholders help develop the system, as they will help build the … This added structure to the reports and allowed more meaningful analysis to occur.

324. Creating a Culture of Patient Safety through Innovative Hospital Design (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Reiling.pdf
     January 01, 2004 - Churchill According to the Institute of Medicine (IOM),1 tens—if not hundreds—of thousands, of errors occur … The majority of errors that occur are considered “near misses”—errors that could have caused harm to … The IOM reported that the probability of a hospital preventable medical death will occur in the range … of 3 to 6 per 1,000 admissions and that an adverse event will occur in the range of 3 to 4 per every … In these types of activities, errors known as slips or mistakes (lapses) can occur for multiple reasons

325. Disclosure Checklist | Agency for Healthcare Research and Quality
     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

326. On-Time Pressure Ulcer Healing: Facilitator Training Instructor's Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/guide.html
     December 01, 2017 - Communicate risk changes as they occur. … Improve root cause analyses when adverse events occur. … Some of the suggested meetings may already occur at the nursing home but may need to be restructured … When would the meeting occur? … How will communication occur with other disciplines to confirm changes in care?

327. Facilitator Guide: Science of Safety Training & Identifying Defects (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_scienceofsafety_facnotes.docx
     December 01, 2017 - Twenty-five percent of inpatient surgeries result in a complication, and about 1 million deaths occur … Errors also occur because systems frequently are not designed to catch mistakes before they reach the … claims, sentinel events, and mortality and morbidity conferences when we want to identify defects that occur

328. Implementation Steps and Timeline | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/impsteps.html
     January 01, 2017 - 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

329. 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/timeline.html
     June 01, 2017 - 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

330. Module 7: Resolution | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes7.html
     August 01, 2022 - Slide 1 Say: When adverse patient events occur, the patient and their family are looking

331. A Model-based Approach to Prioritizing Medical Safety Practices (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Marken.pdf
     January 01, 2004 - tests have been rare.7 One reason for the lack of testing is the actual rate at which medical errors occur … Prescribing errors, for example, occur in 0.4 percent to 1.9 percent of all medication orders, and … Since medical safety practices are applied to the problem of eliminating the errors that occur when … practices are carried out, as well as by psychological theories regarding human errors and why they occur … Preventing medications errors that occur in the home. US Pharm 2004;9:64-8. 43.

332. Final Progress Report: Weekend Effects and the July Phenomenon in Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-09/weissman-report.pdf
     January 01, 2024 - Purpose: The purpose of this study was to examine whether adverse events or complications in hospitals occur … The purpose of this study was to examine whether adverse events or complications in hospitals occur … fact that we only examined eight types of complications out of dozens of known complications that occur

333. Resident and Family Engagement: What is my role as a leader? (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/resources/tools/engage/rfe-role-leader.pdf
     March 01, 2017 - Healthcare-associated infections (HAIs) occur far too often in nursing homes.

334. Module 4: How To Implement the Pressure Injury Prevention Program in Your Organization | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/workshop/slides4.html
     October 01, 2017 - Unit staff tell the Wound Care Team about high-risk patients or if skin problems occur. … Slide 21: Communication Patterns Good communication needs to occur among staff at all levels.

335. It Takes a Team: Preventing Infections in Ambulatory Surgery Centers (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/implementation-guide/appendix-l.pdf
     May 01, 2017 - Surgical site infections are infections that can occur after surgery in the part of the body where

336. Mod5-Disclosure-Checklist (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/mod5-disclosure-checklist.pdf
     April 01, 2016 - tool: Use Part I of the checklist to prepare for the initial disclosure conversation, which should occur

337. Strategies for Improving CAHPS Clinician & Group (CG-CAHPS) Survey Scores (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/20160315/debra-rosen-slides.pdf
     March 15, 2016 - agencies)  Focus priorities at the site or organizational level  Significant change/efforts must occur

338. Low Tidal Volume Ventilation Facts | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/modules/technical/ltvv-fact-sheet.html
     January 01, 2017 - Prevent the lung damage that can occur within a few hours of mechanical ventilation at high tidal volume

339. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/ltvv-factsheet.docx
     January 01, 2017 - Prevent the lung damage that can occur within a few hours of mechanical ventilation at high tidal volume

340. Engage Patients and Families for Perinatal Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/pf-engagement-facilitator-guide.pdf
     May 01, 2017 - Slide 16 SAY: Adverse events occur when a patient is harmed as a result of receiving medical care … Rarely does an adverse event occur as a result of intent.