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341. Medical Product Safety Network (MedSun) Collaborates with Medical Product Users to Create Specialty Subnetworks (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Engleman_86.pdf
     June 04, 2008 - that this approach would increase the likelihood that the FDA would learn about device problems that occur … seemed critical for the pediatric clinical community to be aware of the types of problems that could occur … Such a program would focus on identifying IVD devices and the problems that can occur with them, stressing … Examples of laboratory devices were provided, along with a listing of the problems that could occur … KidNet’s focus is on identifying and reporting all medical device-related adverse events that occur

342. An Analysis of Nurses' Cognitive Work: A New Perspective for Understanding Medical Errors (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Potter.pdf
     January 01, 2003 - Steps in the nursing process are represented in a timeline as they occur along the pathway. … nature of the RN’s work and the RN’s vulnerability to making errors or omissions when cognitive shifts occur … Clearly, cognitive shifts occur in response to patients’ needs, organizational style of the RN, and … Cognitive shifts between patients occur frequently throughout a shift of care and demonstrate the challenge

343. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/module5-response-disclosure-notes.pptx
     August 21, 2015 - not an isolated event, since there are many different points at which disclosure conversations can occur

344. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module7/module7-resolution-facilitator.pptx
     August 24, 2015 - resolution process before and after CANDOR implementation. 2 Module 7 When adverse patient events occur

345. How to Use This Toolkit | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/shuttered/toolkitchecklist/surgetkit1.html
     July 01, 2018 - This should occur every few days at the beginning, and once a week as the facility continues operations

346. What Happens After a Patient Safety Event? Medical Expenditures and Outcomes in Medicare (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Encinosa.pdf
     January 01, 2003 - examined 14 potentially preventable adverse medical events defined by the PSI methodology that can occur

347. The Nature, Characteristics and Patterns of Perinatal Critical Events Teams (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Riley_58.pdf
     April 02, 2008 - We selected obstetrics crises to study team performance for several reasons: • They occur in a compressed … regarding the nature of team formation and reformation in health care and leadership transfer that occur … At the same time, more complications/crisies could occur in real life situations.

348. Mixed Methods Analysis of Medical Error Event Reports: A Report from the ASIPS Collaborative (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Harris.pdf
     June 30, 2004 - interventions were those that focused on identifying (1) weak points in the flow of events at which errors occur … Reported events are only a subset of all medical errors that occur. … Thus, these errors can occur at various points along the chain of activities associated with diagnostic … the procedure event chain the error occurred, how and why it occurred, and why harm did or did not occur … diagnostic testing process and the transition points within and between stages at which errors can occur

349. Preparing for Ambulatory Computerized Prescriber Order Entry by Evaluating Preimplementation Medication Errors (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Devine.pdf
     July 01, 2003 - ambulatory care setting is complex, and that there are numerous points in that process where errors can occur

350. Silence A Commentary | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/liability/silence.html
     August 01, 2017 - Yet, when harm does occur, and honest and transparent conversations are not conducted, you harm us again

351. AHRQ Quality and Safety Review System (QSRS) | Agency for Healthcare Research and Quality
     www.ahrq.gov/cpi/about/otherwebsites/qsrs.ahrq.gov/index.html
     March 01, 2021 - AHRQ Quality and Safety Review System (QSRS) Mission AHRQ has developed and tested an improved patient safety surveillance system to replace the Medicare Patient Safety Monitoring System (MPSMS). The new system is known as the Quality and Safety Review System (QSRS). The QSRS relies on clinical information re…

352. Learning-From-Antibiotic-Adverse (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/learning-from-antibiotic-adverse.docx
     June 01, 2021 - AHRQ Safety Program for Improving Antibiotic Use Learning From Antibiotic-Associated Adverse Events An antibiotic-associated adverse event is any event or situation that you would not want to happen again because it either caused your patient harm or had the potential to cause harm. The purpose of this tool is to provi…

353. Final Progress Report: Pediatric Medication Safety: Analyses from the MEDMARX Medication Error Reporting System (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/bundy-report.pdf
     January 01, 2024 - Categories B through D errors involved situations in which an error did occur, but no harm resulted … suggest that, by targeting these risk factors for harm in the NICU, a significant number of errors that occur

354. Saving Lives and Saving Money: Hospital-Acquired Conditions Update | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/2014-final.html
     January 01, 2018 - Saving Lives and Saving Money: Hospital-Acquired Conditions Update Final Data From National Efforts To Make Care Safer, 2010–2014 Summary Final estimates for 2014 show a sustained 17 percent decline in hospital-acquired conditions (HACs) since 2010. A cumulative total of 2.1 million fewer HACs were experie…

355. National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data From National Efforts To Make Health Care Safer | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/2015-interim.html
     December 01, 2016 - National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data From National Efforts To Make Health Care Safer Summary Preliminary 1 estimates for 2015 show a 21 percent decline in hospital-acquired conditions (HACs) since 2010. A cumulative total of 3.1 million fewer HACs were expe…

356. Patient and Family Engagement | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/modules/patient-family-engagement/notes.html
     September 01, 2013 - Introduction to Adverse Events Say: Adverse events occur when a patient is harmed as a result of … Rarely does an adverse event occur as a result of intent.

357. Module 4: Teamwork and Communication: Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module4/mod4-facguide.html
     March 01, 2017 - Slide 17: For Information Transfer – Handoffs Say: Handoffs occur during a change in assignment … 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

358. Making the Case That Improving Antibiotic Use Is a Patient Safety Issue (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/patient-safety-facilitator-guide.pdf
     November 01, 2019 - Often, these adverse events occur after a patient is discharged from the hospital. … The holes are the errors in your system that occur and risk harming a patient. … Moment 4 should occur as soon as it is clear what infectious process is being treated and the patient

359. System-Focused Event Investigation and Analysis Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4.html
     August 01, 2022 - In addition, learning about system vulnerabilities before they occur is critical. … The CANDOR Response Team is responsible for conducting a preliminary review, which should occur within … The preliminary review should occur at the event location. … understanding of the event: if individual interviews, appropriate information gathering, and observations occur … Please note that the bulk of the time and effort of the event review process should occur during the

360. NPSD Data Spotlight - Patient Safety and COVID-19: A Qualitative Analysis of Concerns During the Public Health Emergency (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-ptsafety-and-covid-19.pdf
     November 01, 2021 - Many areas for errors to occur especially with increase in test volume. … These policy- and procedure-related events are more likely to occur in a rapidly changing environment