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81. 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/exercises4.html
    December 01, 2017 - ( Circle all that apply ) Identify all weights that occur in the range of 170-190 days from the … most recent weight date; select the weight closest to 180 days Identify all weights that occur in the … weight None of the above When determining Weight 30 Days Prior, first identify all weights that occur

82. A Visual Computer Interface Concept for Making Error Reporting Useful at the Point of Care (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Singh_69.pdf
    April 04, 2008 - steps in developing a culture of safety is the recognition by staff and clinicians of errors that occur … These processes are recognized to occur in a cyclical fashion, as shown by the clockwise progression … system, especially with respect to errors and opportunities for errors, including errors that may occur … In the emergency room (circle no. 2), similar cycle(s) of care occur, starting with Assessment (point … , contributors that might be present, and consequences that can occur, thereby improving situational

83. Data Measures Guide (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/vae/datameasures-guide.pdf
    January 01, 2017 - , o 3 have adverse event (9) occur, o 2 have adverse event (18) occur, and o 3 have adverse event … (20) occur. … ) occur and 30% of the patient days had adverse event (20) occur Target Accurate documentation of … (20) occur. … ) occur and 30% of the patient days had adverse event (20) occur Target Accurate documentation of

84. 6 Tk1 T2-Talking With Residents Family Members Checklist Version Final (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/nhguide/6_TK1_T2-Talking_with_Residents_Family_Members_checklist_version_Final.pdf
    October 01, 2016 - There are five potential health problems that occur as a result of taking an antibiotic. 1. … • Although we cannot be certain that any of these problems will occur, it is important that you and

85. 6 Tk1 T2-Talking With Residents Family Members Checklist Version Final (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/nhguide/6_TK1_T2-Talking_with_Residents_Family_Members_checklist_version_Final.docx
    October 01, 2016 - There are five potential health problems that occur as a result of taking an antibiotic. 1. … Although we cannot be certain that any of these problems will occur, it is important that you and your

86. University of Iowa Uses AHRQ Data to Study Ways to Lower Incidence, Costs of Sports-Related Injuries | Agency for Healthcare Research and Quality
    www.ahrq.gov/news/newsroom/case-studies/cdom0803.html
    October 01, 2014 - At least 4.3 million sports and recreational injury episodes occur each year in school-aged children … In the U.S., more than 300,000 sports-related traumatic brain injuries (TBIs) occur each year, and many

87. Prologue: Technology and Medication Safety (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Prologue_Grady_Vol4.pdf
    June 02, 2025 - about privacy and the security of health data, and the unintended consequences that can sometimes occur … Medication errors are a frequent cause of adverse drug events, and they can occur at any point in the

88. Introduction | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions1.html
    June 01, 2023 - Academy of Medicine. 1 An underrecognized and high-risk moment in patients’ diagnostic journeys can occur

89. AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Electronic Fetal Monitoring (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/safe-electronic/tool_safe-e-fetal-monitoring.docx
    May 01, 2017 - 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

90. Auditing Strategies to Improve Infection Prevention Processes in Nursing Homes | Agency for Healthcare Research and Quality
    www.ahrq.gov/nursing-home/materials/prevention/observational-audits.html
    July 01, 2021 - Observational Audits Observational audits occur while staff are in the work environment and help obtain

91. Final Progress Report: Patient Safety in Hospice Care (pdf file)
    www.ahrq.gov/sites/default/files/2024-10/smucker-report.pdf
    January 01, 2024 - and categorize the types, characteristics, and contributing factors of patient safety incidents that occur … readily identifiable, preventable, and severe potential for harm) used to define “never events” that occur … contexts of home hospice care suggest unique types and patterns of patient safety incidents that may occur … • Pain crises or other needs for sudden changes in care plans frequently occur during home hospice … Significance This proposed study resulted in the first reported descriptions of adverse events that occur

92. PowerPoint Presentation: Learn From Defects Through Sensemaking
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects.pptx
    December 01, 2017 - Why 2: Why did the answer to “Why 1” occur? Why 3: Why did the answer to “Why 2” occur? … Why 4: Why did the answer to “Why 3” occur? Why 5: Why did the answer to “Why 4” occur? … Why did the contributing factor occur? … It did not occur to anyone that this patient could be misidentified. … Does it occur rarely or have a high likelihood of reoccurring?

93. Access of Central Venous Catheter for Initiation of Dialysis Procedural Checklist 1a (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/esrd/procchecklist1a-access-cvc.pdf
    June 02, 2025 - gloves ☐ Hand hygiene Note: If troubleshooting or manipulation of catheter or dialysis lines must occur

94. TeamSTEPPS Team Leadership Module 2
    www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/curriculum/teamstepps-module-2-slides.pptx
    June 02, 2025 - the components and composition of a multi-team system. 3 3 Team Structure Teamwork cannot occur … Where did the breakdowns occur between the components of this multi-team system? … Leadership Debriefs foster process improvement: Brief, informal information exchange and feedback sessions Occur

95. Chapter 2. Analyze Care Delivery | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/vtguide/guide2.html
    February 01, 2016 - steps and to identify where failures—or missed chances to prevent hospital-associated VTE (HA-VTE)—occur … For those steps that occur less than 100 percent of the time, the team will want to identify things that … prioritize these failure modes and to put some effort into delving into the root causes of why they occur

96. Chapter 2. Analyze Care Delivery | Agency for Healthcare Research and Quality
    www.ahrq.gov/es/patient-safety/settings/hospital/vtguide/guide2.html
    February 01, 2016 - steps and to identify where failures—or missed chances to prevent hospital-associated VTE (HA-VTE)—occur … For those steps that occur less than 100 percent of the time, the team will want to identify things that … prioritize these failure modes and to put some effort into delving into the root causes of why they occur

97. Supplemental Items for the CAHPS Clinician & Group Adult Survey: Interpreter Services | Agency for Healthcare Research and Quality
    www.ahrq.gov/cahps/surveys-guidance/item-sets/literacy/suppl-interpreter-service-items-cg-survey30-adult.html
    December 01, 2023 - Some items cover events that occur with low frequency in the general population.

98. Changing-System-Facilitator-Guide (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-facilitator-guide.docx
    June 01, 2021 - Slide 4 Active Failures SAY: Active failures occur because of human error. … Swiss Cheese Model SAY: Let’s return to our “Swiss cheese model” to help visualize where mistakes can occur … As you can see, along the process of an antibiotic prescribing decision, latent failures can occur if … Without these defenses, an “active” or human failure can occur, resulting in a poor outcome. … Change cannot occur if the workforce is not aware and engaged, so share the results from your hard work

99. Selected Best Practices and Suggestions for Improvement (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4k_combo_psi14-dehiscence-bestpractices.pdf
    May 20, 2016 - Recommended Practice: Postoperative Wound Assessment • Documentation of the surgical wound should occur … 48 hours after surgery to establish a baseline.1,2,7 • Repeat assessment should occur every shift … Education should occur upon hire, annually, and when this protocol is added to job responsibilities.1

100. Pre-intervention Assessment: Adapting and Implementing Patient Safety Practices in Ambulatory Care (xls file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/safetransitions/hret-preinterventionasst.xlsx
     June 02, 2025 - Assessment of Patient and Family Engagement Values and Practices Indicate how frequently the following occur … Preparation Preparing the Patient for their Next Appointment Indicate how frequently the following occur … A3 Appointments Appointments Indicate how frequently the following occur in your facility by marking … A3 The Health Care Team The Health Care Team Indicate how frequently the following occur in your facility … A3 Care Partner Care Partner Questions Indicate how frequently the following occur in your facility