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381. AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/reports.html
     November 01, 2017 - The fall-related meetings listed are examples of those that may occur in a nursing home.

382. Interim Update on 2013 Annual Hospital-Acquired Condition Rate (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/2014finalhacreport-cx.pdf
     December 01, 2016 - Interim Update on 2013 Annual Hospital-Acquired Condition Rate December 2016 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…

383. Final Data From National Efforts To Make Care Safer, 2010-2014 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/2014FinalHACreport4Web-13Dec2016.pdf
     December 01, 2016 - Final Data From National Efforts To Make Care Safer, 2010-2014 December 2016 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…

384. 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/measuredesc-dailyearlymobility-facguide.docx
     January 01, 2017 - measurement, it’s recommended to choose the value closest to 10 a.m. because this is usually when rounds occur … performed, it’s recommended to choose the value closest to 10 a.m. because this is usually when rounds occur

385. Tool 4: How To Deliver the Re-Engineered Discharge to Diverse Populations | Agency for Healthcare Research and Quality
     www.ahrq.gov/es/patient-safety/settings/hospital/red/toolkit/redtool4.html
     March 01, 2025 - patients with diverse health beliefs, language preferences, cultural norms, and health-seeking behaviors occur … misunderstandings about the nature of an illness, its remedies, and appropriate health behaviors are more likely to occur … Cross-cultural communication, which requires an exchange of shared meaning, can occur even when both … This can be due to a range of phenomena, including fear of the shame that could occur if the patient's … appointments, you can reference the calendar to determine whether any special religious observances will occur

386. Tool 4: How To Deliver the Re-Engineered Discharge to Diverse Populations | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/red/toolkit/redtool4.html
     March 01, 2025 - patients with diverse health beliefs, language preferences, cultural norms, and health-seeking behaviors occur … misunderstandings about the nature of an illness, its remedies, and appropriate health behaviors are more likely to occur … Cross-cultural communication, which requires an exchange of shared meaning, can occur even when both … This can be due to a range of phenomena, including fear of the shame that could occur if the patient's … appointments, you can reference the calendar to determine whether any special religious observances will occur

387. Diagnostic Failure: A Cognitive and Affective Approach (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Croskerry.pdf
     January 01, 2004 - Errors of ignorance are due to inadequate knowledge, whereas errors of implementation occur during application … No-fault diagnostic errors occur when the disease is silent, appears in an atypical fashion, or mimics … An exception may occur if a physician experienced a particularly bad outcome with a missed diagnosis … Fatigue may occur independently of sleep deprivation and sleep debt, but these invariably lead to fatigue … exercise is to provide meaningful, realistic self-feedback so that insight will develop, learning will occur

388. Chapter 3. Structure of Learning Network | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/diabetesnetwork/diabnet3.html
     October 01, 2014 - Hispanic Diabetes Disparities Learning Network in Community Health Centers Chapter 3. Structure of Learning Network Previous Page Next Page Table of Contents Hispanic Diabetes Disparities Learning Network in Community Health Centers Chapter 1. Introduction Chapter 2. Project Description Chapte…

389. Case Report on Ambulatory Safety and Quality (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/lab-testiing/lab-testing-casereport.pdf
     September 05, 2017 - o Where does the process typically occur?  Where does each step occur? …  Does notation need to occur? o What technology is used in the process? …  How does communication occur between practice and external agency? … o Where does the process typically occur?  Where does each step occur? …  How does communication occur between practice and external agency?

390. Final Progress Report: Improving Safety of Transitions to Skilled Nursing Care Using Video Conferencing (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/lipsitz-report.pdf
     January 01, 2024 - We found that errors were more likely to occur for patients discharged from surgical services or the … emergency department (ED; compared with discharge from medical services) and were less likely to occur

391. Using Six Sigma® Methodology to Improve Handoff Communication in High-Risk Patients (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Mistry_114.pdf
     May 05, 2008 - Building a Safer Health System, the Institute of Medicine (IOM) estimated that up to 98,000 deaths occur … Research suggests that communication failures frequently occur during the operative procedure, with … We hypothesized that: (1) communication errors commonly occur during the postoperative handoff process

392. Best Practices in the Diagnosis and Treatment of Community-Associated Lower Respiratory Tract Conditions (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/best-practices/respiratory-facilitator-guide.pdf
     November 01, 2019 - Best Practices in the Diagnosis and Treatment of Community-Associated Lower Respiratory Tract Conditions AHRQ Safety Program for Improving Antibiotic Use 1 AHRQ Pub. No. 17(20)-0028-EF November 2019 Best Practices in the Diagnosis and Treatment of Community-Associated Lower Respiratory T…

393. Final Progress Report: Real-time assessment of risk factors for medication errors (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/dresselhaus-report.pdf
     January 01, 2024 - nonpreventable adverse drug reactions (due to the inherent properties of the agent), medication errors may occur … Although most of the adverse drug events that occur during the study period will be linked to a specific … provider and captured in the day, hour, and sometimes minute they occur, some will not, making it more

394. Objective Outcomes Data Collection Tool | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/modules/vae/objective-outcome-tool.html
     January 01, 2017 - Objective Outcomes Data Collection Tool AHRQ Safety Program for Mechanically Ventilated Patients Hospital ___________            Unit___________                   Month ___________ Please record the following occurrences for all patients in your unit within the selected month. ________ Total…

395. Action-Plan-Template (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/action-plan-template.docx
     April 01, 2022 - Unit Action Plan The Comprehensive Unit-based Safety Program (CUSP) or healthcare-associated infection (HAI) leader is responsible for leading the CUSP team in completing an Action Plan in order to drive work related to lowering bloodstream infections (CLABSI) and/or catheter-associated urinary tract infections (CAUTI)…

396. Final Progress Report: Profiling the Needs of Dying Children (pdf file)
     www.ahrq.gov/sites/default/files/2024-10/feudtner-report.pdf
     January 01, 2024 - epidemiological transition’ in pediatric mortality – from mostly accidental and sudden death to deaths that occur … genetic, neuromuscular, and metabolic conditions, and other forms of cancer were all more likely to occur

397. Envisioning Patient Safety in the Year 2025: Eight Perspectives (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Henriksen_104.pdf
     January 01, 2025 - When errors do occur, our pride leads us to respond with surprise (This should never happen here!) … Because of powerful vested interests, change will not occur without substantial increases in public … Handoffs between providers will occur electronically. … vision of “patient-centeredness” within patient safety in 2025, the necessary changes that need to occur … To develop those new ways of thinking and better understanding, three fundamental changes must occur

398. AHRQ's Safety Program for Nursing Homes: On-Time Falls Prevention Training (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallpxreports-ig.pdf
     June 02, 2025 - Falls that occur within 1-7 days of the report date will be noted in high risk based on change of condition … Falls that occur within 1-7 days of the report date will be noted in high risk based on change of condition … Likewise, if multiple minor injuries occur, they will only be counted as one and if multiple major … injuries occur, they will only be counted as one. … Regardless of whether the report is monthly or quarterly, a room change must occur within 30 days

399. NICU Family Information Packet, Appendix B, Growth (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-growth.pdf
     June 02, 2025 - NICU Family Information Packet, Appendix B, Growth Growth General Growth ■ Use growth charts made specifically for premature infants. ■ After infant reaches term corrected gestational age, a standard growth chart may be used. ■ Use corrected postmenstrual age until 2 years of age. ■ Interpretations of catch-u…

400. The Relationship Between Hospital Workload and Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-09/weissman-rothschild-report.pdf
     January 01, 2024 - determine the extent to which hospital workload pressures affect the rate at which adverse events (AEs) occur … working conditions, specifically workload pressures, affect the rate at which adverse events (AEs) occur … Our key study question was as follows: Do adverse events in hospitals occur more often on crowded or … The goal was to determine if adverse events were more likely to occur on peak workload days over the … Even though the average workload differed, we thought that peak workload effects would occur regardless