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  1. www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-ai-wave5.html
    July 01, 2025 - rarely make errors, clinicians may become less vigilant over time and fail to catch the few that do occur—an
  2. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/hotline/hotline-appendixa.pdf
    June 02, 2025 - Appendix A. Recommendations for Ideal Consumer Reporting Systems Appendix A. Recommendations for Ideal Consumer Reporting Systems A 2010 report by Research Triangle Institute (RTI) and Consumers Advancing Patient Safety, Designing Consumer Reporting Systems for Patient Safety Events, outlined recommendations for…
  3. www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/item-sets/literacy/supplemental-interpreter-hpcahps-adult_2157-4a.docx
    June 02, 2025 - Some items cover events that occur with low frequency in the general population.
  4. www.ahrq.gov/hai/tools/mrsa-prevention/toolkit/cusp.html
    October 01, 2024 - In the CUSP model, defects are understood as the product of the systems in which they occur.
  5. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Davis_60.pdf
    April 07, 2008 - Unlike simulations that occur in a laboratory setting, in situ simulation is a strategy that takes place … Severity How severe the outcome is to the patient should failure occur. … Cost is certainly a factor, but as simulation becomes more commonplace, efficiencies will occur.
  6. www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/about/impact-stories/enabling-real-time.pdf
    January 01, 2023 - Enabling Real-Time Identification of Burnout Risk Among Clinicians in Primary Care Practices Enabling Real-Time Identification of Burnout Risk Among Clinicians in Primary Care Practices AHRQ Impact: Researchers have developed a prediction tool to identify primary care practices at high-risk of clinician burnout…
  7. www.ahrq.gov/funding/grantee-profiles/grtprofile-leiferman.html
    May 01, 2024 - Mental health conditions, including perinatal or maternal depression that occur during pregnancy and
  8. www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/item-sets/literacy/interpreter-hpcahps-adult-spanish-2157-4b.docx
    June 02, 2025 - Some items cover events that occur with low frequency in the general population.
  9. www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/sustainability-plan.pdf
    June 01, 2021 - Best outcomes are most likely to occur when the Antibiotic Stewardship Team shares common goals and … Stewardship Team leaders should be able to motivate staff when deviations from the Safety Program occur—for … Moments of antibiotic prescribing on 5–10 residents each month to understand what changes may need to occur
  10. www.ahrq.gov/data/infographics/hac-scorecard-2014-16.html
    November 01, 2019 - HAC National Scorecard 2014-16 Between 2014-2016, 350,000 fewer hospital-acquired conditions (HACs) occurred, an 8% decrease that saved $2.9 billion and averted 8,000 inpatient deaths. Learn more in the AHRQ report, " National Scorecard on Rates of Hospital-Acquired Conditions ." HAC National Scorecard 2014…
  11. www.ahrq.gov/sites/default/files/wysiwyg/nhguide/6_TK1_T1-Talking_with_Residents_checklist_version_Final.pdf
    October 01, 2016 - There are five potential health problems that occur as a result of taking an antibiotic. 1.
  12. www.ahrq.gov/sites/default/files/wysiwyg/nhguide/6_TK1_T1-Talking_with_Residents_checklist_version_Final.docx
    October 01, 2016 - There are five potential health problems that occur as a result of taking an antibiotic. 1.
  13. www.ahrq.gov/sites/default/files/2024-02/herwaldt-report.pdf
    January 01, 2024 - technology, and a new online data-capture-response tool to prevent patient identification errors that occur … technology, and a new online data-capture-response tool to prevent patient identification errors that occur
  14. www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-terminology5.html
    April 01, 2025 - movement gave rise to new concepts such as: Never events 18 (the most egregious events that should never occur … focuses on system design, constraints, and standardization to prevent harm and asserts that problems occur
  15. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/warm-handoff-design-guide-final508.pdf
    June 02, 2025 - Next, you need to understand how the many types of transitions currently occur.
  16. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/vae/objective-outcome-tool.docx
    January 01, 2017 - Facilitator Guide: Build Your SSI Prevention Bundle Hospital ___________ Unit___________ Month ___________ Please record the following occurrences for all patients in your unit within the selected month. ________ Total number of patients on mechanical ventilation ________ Total number of episodes of mechani…
  17. www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/nursing-protocols/nursing-practice-guide.docx
    March 01, 2022 - Nursing Practice Guide Section 9-5 – Decolonization of Non-ICU Patients With Devices Nursing Practice Guide Use this guide to help ensure that all nursing practice processes and leadership support are in place to actively support the decolonization intervention. Engagement and Collaboration CHG Bath Documentation N…
  18. www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/nursing-protocols/nursing-practice-guide.pdf
    March 01, 2022 - Nursing Practice Guide AHRQ Pub. No. 20(22)-0036 March 2022 Section 9-5 – Decolonization of Non-ICU Patients With Devices Nursing Practice Guide Use this guide to help ensure that all nursing practice processes and leadership support are in place to actively support the decolonization intervention. CHG = c…
  19. www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/best-practices/asp-pneumonitis-one-page.pdf
    November 01, 2019 - Aspiration Pneumonitis/Pneumonia Diagnosis • Aspiration pneumonitis is an abrupt chemical injury caused by inhalation of sterile gastric contents. o It can progress quickly to a decline in respiratory status followed by rapid improvement within 48 hours of the insult. o Chest x rays appear similar to multi…
  20. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Anthony.pdf
    January 01, 2005 - Forster, et al.4 provide data demonstrating that many adverse events occur at the time of hospital discharge … Errors occur when latent conditions or system failures occur that are the consequences of failures in … Many adverse effects occur during the peridischarge period, and many could be prevented with relatively … industries as a proactive, systematic way of examining processes for possible ways in which failure can occur … • Patient education must occur throughout the hospitalization, not only at the time of discharge

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