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1. Module 1: An Overview of the CANDOR Process | Agency for Healthcare Research and Quality
   www.cahps.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes1.html
   August 01, 2022 - This table demonstrates just a few of the changes that must occur to realize the goals of the CANDOR … After the CANDOR System Activation occurs, the 3 rd and 4 th components should occur simultaneously … The following activities should occur at this time: the Core Team will schedule and complete interviews … The second part should occur within 30-45 business days after a CANDOR event has been identified. … Resolution of the event can only occur after Event Investigation and Analysis has been completed.

2. Development and Validation of the Medication Administration Error Reporting Survey (pdf file)
   www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Wakefield2.pdf
   January 01, 2003 - Five subscales emerged for “reasons why MAE occur”; four subscales emerged for “reasons why MAE are … medication administration errors occur. … Reasons why medication errors occur (19 items in 1994 and 29 in subsequent surveys). 2. … In the first content area, “why MAEs occur,” five factors emerged. … Nurses’ perceptions of why medication administration errors occur.

3. Leading Teams (Instructor Guide) (pdf file)
   www.cahps.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module4/ts2-0ltc_module4_ig_lead.pdf
   May 10, 2017 - Did the items on this checklist occur? If not, what was not done? … When would the briefing occur? … In addition, information updates within the team should occur as often as necessary. … Did the items on this checklist occur? If not, what was not done? … When would the briefing occur? Who would be expected to attend? 1.

4. Job Aid: Process Mapping (pdf file)
   www.cahps.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/job-aid-process-mapping.pdf
   May 17, 2021 - specific actions of different individuals (or departments) in the process and the places where handoffs occur … Remind participants to use appropriate symbols, stack actions that occur at same time, and reevaluate

5. Implementation Guide for the CANDOR Process | Agency for Healthcare Research and Quality
   www.cahps.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

6. Understand-Facilitator-Guide (doc file)
   www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-facilitator-guide.docx
   May 01, 2017 - Slide 3 SAY: Errors occur within the health care setting because health care professionals are human … Providers, executives, and managers need to understand why errors occur. … Errors occur because medicine is still treated as an art, not a science. … In analyzing how errors occur, frontline providers must recognize the scientific nature of medicine. … Errors also occur because systems frequently do not catch mistakes before they reach the patient.

7. 6 Tk1 T2-Talking With Residents Family Members Checklist Version Final (pdf file)
   www.cahps.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

8. Understand the Science of Safety for Perinatal Safety (pdf file)
   www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-facilitator-guide.pdf
   May 01, 2017 - SAY: Errors occur within the health care setting because health care professionals are human, and … Providers, executives, and managers need to understand why errors occur. … Errors occur because medicine is still treated as an art, not a science. … In analyzing how errors occur, frontline providers must recognize the scientific nature of medicine … Errors also occur because systems frequently do not catch mistakes before they reach the patient.

9. Adverse Drug Events Occurring in U.S. Hospitals | Agency for Healthcare Research and Quality
   www.cahps.ahrq.gov/data/infographics/adverse-drug-events.html
   August 01, 2018 - Skip to main content An official website of the Department of Health and Human Services Careers Contact Us Español FAQs Search all AHRQ sites Search small Search Menu …

10. Advancing Diagnostic Safety: An AHRQ Leadership Conversation | Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/news/blog/ahrqviews/diagnostic-safety-conversation.html
    October 01, 2021 - just a subset of the data that are out there, and we have enough to confirm that diagnostic errors occur … DM: Why do diagnostic errors occur in the first place? … This focus can occur even when their current patient’s history or symptoms suggest a different diagnosis … Systemic errors, in contrast, can occur when processes within organizations aren’t designed well or don

11. Using Patient Input to Improve Diagnostic Safety | Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/funding/grantee-profiles/grtprofile-bell.html
    March 01, 2022 - Diagnostic errors occur in part because diagnosis itself is a multi-layered process, potentially involving … Documentation errors occur frequently, with about one in five patients reporting a perceived serious … Bell and her team developed and tested the framework for patient-reported diagnostic breakdowns that occur

12. Applying a Novel Organization Change Scale in a Multisite Patient Safety Initiative | Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/patient-safety/reports/liability/brock.html
    August 01, 2017 - interventions focused on patient safety generally have not proven effective. 2-4 When success does occur … Disclosure coaches strengthen clinician confidence and allow disclosure to occur in a timely fashion. … Our organizations’ leaders and stakeholders hold a shared vision that organizational change needs to occur … organization’s leaders and stakeholders hold a shared vision of what organizational change needs to occur … organization’s leaders and stakeholders hold a shared vision of how organizational change needs to occur

13. Chapter 2: Five Key Recommendations To Improve Patient Safety for LEP Patients | Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/health-literacy/professional-training/lepguide/chapter2.html
    September 01, 2020 - engage in a systematic approach to better identify and prevent medical errors and adverse events that occur … Medical Errors Among LEP Patients Background To accurately identify and analyze medical errors that occur … need of improvement to ensure that staff are empowered and can identify and report medical errors that occur … not receive training on what constitutes an error or a near miss, or on how to report these when they occur … Hospitals rarely analyze events that occur among culturally diverse and LEP patients.

14. Understand the Science of Safety for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/understand-sci-fac-guide.html
    July 01, 2023 - Say: Errors occur within the health care setting because health care professionals are human, and humans … Providers, executives, and managers need to understand why errors occur. … Errors occur because medicine is still treated as an art, not a science. … In analyzing how errors occur, frontline providers must recognize the scientific nature of medicine. … Errors also occur because systems frequently do not catch mistakes before they reach the patient.

15. Surge in Drug Shortages Occurred in Wake of Pandemic, Study Finds | Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/news/newsletters/e-newsletter/908.html
    April 01, 2024 - Skip to main content An official website of the Department of Health and Human Services Careers Contact Us Español FAQs Search all AHRQ sites Search small Search Menu …

16. AHRQ Tribal Consultation Policy | Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/cpi/about/mission/strategic-plan/tribal-consultation-policy.html
    August 01, 2014 - Policy It is the policy of AHRQ that consultation with Federally-recognized Indian Tribes will occur … Consultation shall occur on a regular basis and may occur on an "as needed" basis as well. … The Agency will also take part in the Department's annual national Tribal budget consultations which occur … Other types of meetings and/or conferences occur in which tribal leaders/representatives and Agency leaders

17. Appendix B: Bringing It To Life - Case Study | Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/health-literacy/professional-training/lepguide/app-b.html
    September 01, 2020 - It is important to focus on the processes of care that do or do not occur leading to poor communication … patient safety. 64 , 65 While this case may seem extreme, research shows that errors like these occur … patient safety for LEP patients so that they can track these situations and learn from errors that occur

18. Four Moments of Antibiotic Decision Making | Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/antibiotic-use/acute-care/four-moments/index.html
    November 01, 2019 - This can occur as early as after the first day the patient is on antibiotics; thus, the Moment 3 questions … Moment 4 should occur when the patient’s diagnosis becomes clear.

19. Selected Best Practices and Suggestions for Improvement (pdf file)
    www.cahps.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

20. Module 2 Instructor Slides (pdf file)
    www.cahps.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module2/ts2-0ltc_module2_slides_team.pdf
    June 12, 2017 - teams interact is critical for implementation planning Team Structure • Teamwork cannot occur … Mod 2 LTC 2.0 Page 16 • Ancillary and support services • Where did the breakdowns occur between the