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81. Chapter 4. Conclusions and Next Steps | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/findings/final-reports/stpra/stpra4.html
    April 01, 2018 - As improvements in the SASD, NIS, and the SEDD databases occur, additional information regarding the … Intervention implementation can occur with or without regulatory oversight; however, the ability to hold … providers accountable for performance in these settings over time is most likely to occur with the establishment … Once the performance steps are identified, education needs to occur, with feedback that addresses the

82. Healthy Living: Infant Mortality | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/womenhealth/wm-hl.html
    September 01, 2015 - Approximately two-thirds of infant deaths occur in the neonatal period or within 1 month and one-third … occur in the postneonatal period from 1 month to less than 1 year.

83. Appendix A. Exclusion Criteria | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/cusp/clabsi-final-companion/clabsicompapa.html
    January 01, 2013 - To be included, publications had to be full articles, (abstracts were excluded) and CLABSIs had to occur

84. 10 Patient Safety Tips for Hospitals | Agency for Healthcare Research and Quality
    www.ahrq.gov/patients-consumers/diagnosis-treatment/hospitals-clinics/10-tips/index.html
    June 01, 2018 - 10 Patient Safety Tips for Hospitals Medical errors may occur in different health … minute DVD provides video excerpts of 50 actual chest tube insertions to illustrate problems that can occur

85. Introduction | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/reports/issue-briefs/distributed-cognition-er-nurses1.html
    August 01, 2022 - References Each year, approximately 141 million emergency department (ED) visits occur

86. CANDOR Helped Significantly Reduce Patient Safety Events, Malpractice Claims at MedStar Health | Agency for Healthcare Research and Quality
    www.ahrq.gov/news/newsroom/case-studies/201712.html
    September 01, 2017 - CANDOR process emphasizes the importance of reporting unanticipated patient harm events as soon as they occur … "With increased reporting and learning from these events when they occur, we can improve our systems

87. Monitoring for Perinatal Safety: Electronic Fetal Monitoring | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/safe-electronic-tool.html
    July 01, 2023 - determined, and staff should know what resources are available should a sudden change in patient status occur … Recurrent decelerations: occur with ≥ 50% contractions in any 20-min window. … Intermittent decelerations: occur with < 50% contractions in any 20-min window. … Timing : may occur with or without contractions. … Timing : In most cases, the onset, nadir, and recovery occur after the beginning, peak, and ending of

88. Supplemental Items for the CAHPS Health Plan Adult Survey 5.0: Medical Supplies | Agency for Healthcare Research and Quality
    www.ahrq.gov/cahps/surveys-guidance/item-sets/hp/suppl-medical-supplies-hp-adult.html
    December 01, 2018 - Some items cover events that occur with low frequency in the general population.

89. Patient, Family Member, and Clinician Perceptions of Disclosure of Adverse Events in Labor and Delivery | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/resources/liability/baker.html
    August 01, 2017 - families in the care team and how to communicate with patients about the risks and mistakes that can occur … kinds of information should be disclosed regarding each event and explore how communication should occur … Second, we wanted to ascertain how patient and family and provider communication should occur to mitigate … Last, we interviewed 12 clinicians about the common failures that can occur leading to each event. … The highest level of agreement was for those failures that could occur during the Delivery phase for

90. Patient Safety Information for Providers | Agency for Healthcare Research and Quality
    www.ahrq.gov/data/monahrq/myqi/safety_prov.html
    June 01, 2021 - of Patient Safety Despite the best intentions, a high rate of largely preventable adverse events occur … patients Top Reducing Health Care Associated Infections (HAIs) Health care associated infections occur

91. Concept: Conflict in Teams | Agency for Healthcare Research and Quality
    www.ahrq.gov/teamstepps-program/curriculum/mutual/tools/conflict.html
    July 01, 2023 - Concept: Conflict in Teams It is important to acknowledge that conflict can occur between staff

92. Final Report: Using Risk Models To Improve Safety With Dispensing High-Alert Medications in Community Pharmacies (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/cohen-report.pdf
    January 01, 2024 - The basic events represent 1) exposure rates, or how often certain activities occur; 2) fundamental … Prescribing an incorrect or inappropriate dose of fentanyl patches was estimated to occur in one per … Dosing ranges overlap, so out-of-range dose alerts occur infrequently. … These errors are rarely corrected if data entry verification and patient counseling do not occur. … Patient counseling was estimated to occur with 30% of patients.

93. Tool 3A: Master Clinical Pathway for Inpatient Falls | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/clinical-pathway.html
    January 01, 2013 - Background: The purpose of this tool is to provide an overview of how fall prevention care processes could occur

94. TeamSTEPPS 2.0 Quick Reference Guide to TeamSTEPPS Action Planning (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/reference/quickrefguide.pdf
    March 13, 2014 - be achieved, who will be involved (whose behavior will change), and when and where the change will occur … Write the process steps as they currently occur, identifying who is doing what, when, with what tools … each trainee audience, including who will attend, what will be taught, when and where sessions will occur

95. How To Use the Toolkit | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/surgery/how-to-use.html
    December 01, 2017 - two guides address adaptive and technical work, which are both critical elements for improvement to occur

96. Chapter 6. Discussion and Policy Implications | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/chapter6.html
    August 01, 2022 - indicated that the consumer perspective may be particularly important for patient safety events that occur … system features (often substantially removed from the consumer) that enabled a patient safety event to occur … attempt to both prevent patient safety events from occurring and understand the causes of events that do occur … This may particularly apply to patient safety events that occur in outpatient settings, where there is … Decisions regarding system functions/activities that occur at the "system hub" versus those that occur

97. AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/3.html
    December 01, 2017 - Static Week Calculation: Identify all weights that occur in the range of 170-190 days from the most … 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 25-35 days from the most … The Previous Weight does not need to occur in the week just prior to the most recent week.

98. TeamSTEPPS for Office-Based Care: Implementation Planning | Agency for Healthcare Research and Quality
    www.ahrq.gov/teamstepps/officebasedcare/module11/office_impplan-ig.html
    September 01, 2015 - Write down the process steps as they currently occur and identify who is doing what, when, and with what … intervention: what will be achieved, who will be involved, and when and where the change will occur … Outcome aims focus on changes that occur because your staff carries out the intervention. … Write down the process steps as they currently occur and identify who is doing what, when, and with … When the training sessions will occur and for how long. Where the sessions will occur.

99. Final Progress Report: Evaluation of Risk by Active Surveillance in the Emergency Department (ERASED) (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/hall1-report.pdf
    January 01, 2024 - Active surveillance aids in the detection and description of a wide range of errors as they occur. … is a systematic, proactive method of process evaluation that identifies where and how failures may occur … reporting methods, and FMEA to identify, characterize, and categorize errors, both active and latent, that occur … in this project was to identify and quantify, using active surveillance, nonideal care events that occur … In other words, in an ED, it is possible that evaluation, diagnostics, and treatment may occur interlaced

100. Implementation Guide for the CANDOR Process | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/impguide.html
     August 01, 2022 - For example, more than 1.5 million preventable infections occur annually among inpatients. … While these two processes occur at the same time during the CANDOR process, they have been numbered for … While an initial disclosure conversation will occur within 60 minutes after the CANDOR event occurs, … a full disclosure will typically not occur until after the Event Investigation and Analysis has been … Figure 2: CANDOR Implementation Phases Phase I: Assessments Phase I activities should occur during