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1. Appendix, Develop a Flowchart of Your Current Medication Reconciliation Process | Agency for Healthcare Research and Quality
   www.cpsi.ahrq.gov/patient-safety/settings/hospital/match/appendix/app-5.html
   July 01, 2022 - When does reconciliation occur? … When does the followup occur? … When does the followup occur? … When does this occur? … When does the followup occur?

2. NICU Family Information Packet, Appendix B, Patent Ductus Arteriosus (pdf file)
   www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-pda.pdf
   December 13, 2013 - ■ If the ductus is open at the time of hospital discharge, followup with a cardiologist should occur … – Earlier followup should occur if poor weight gain, difficulty feeding, and tachypnea develop. … Management ■ If spontaneous closure does not occur, closure should be performed to: – Eliminate pulmonary

3. Module 1: An Overview of the CANDOR Process | Agency for Healthcare Research and Quality
   www.cpsi.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.

4. Action Planning Worksheets | Agency for Healthcare Research and Quality
   www.cpsi.ahrq.gov/teamstepps/instructor/essentials/implguide2.html
   November 01, 2018 - Understands the processes of care within workspace where changes will occur. … When does the "problem" occur? … When will the improvement occur? Within what timeframe?   … When will the improvement occur? Within what timeframe?   … When will the improvement occur? Within what timeframe?  

5. TeamSTEPPS for Office-Based Care: Implementation Workbook | Agency for Healthcare Research and Quality
   www.cpsi.ahrq.gov/teamstepps/officebasedcare/impworkbook.html
   December 01, 2015 - Understands the processes of care within workspace where changes will occur. … When does the "problem" occur? … When will the improvement occur? Within what timeframe?   … When will the improvement occur? Within what timeframe?   … When will the improvement occur? Within what timeframe?    

6. TeamSTEPPS for Office-Based Care Implementation Workbook (pdf file)
   www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/officebasedcare/impworkbook.pdf
   December 11, 2015 - clinical subject matter  Understands the processes of care within workspace where changes will occur … When will the improvement occur? Within what timeframe? … When will the improvement occur? Within what timeframe? … When will the improvement occur? Within what timeframe? … Write down the process steps as they currently occur and identify who is doing what, when, with what

7. Briefing Exercise Sheet (pdf file)
   www.cpsi.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module4/ts2-0ltc_module4_briefing_exsheet.pdf
   April 24, 2017 - When will the briefing occur? iii. Where will the briefing occur? B.

8. Development and Validation of the Medication Administration Error Reporting Survey (pdf file)
   www.cpsi.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.

9. The Ten Steps of Action Planning  | Agency for Healthcare Research and Quality
   www.cpsi.ahrq.gov/teamstepps/instructor/essentials/implguide1.html
   November 01, 2018 - Outcome aims focus on changes that occur because your staff carries out the intervention. … Rates are calculated by dividing the number of events that did occur by the total number of opportunities … for the event to occur. … This measure is particularly useful for clinical processes that should occur within a limited period … When the training sessions will occur and for how long. Where the sessions will occur.

10. Implementation Planning | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/teamstepps-program/curriculum/implement/activity/plan.html
    February 01, 2024 - Write down the process steps as they currently occur and identify who is doing what, when, and with which … what you hope will be achieved, who will be involved, and when and where the improvements will occur … Outcome aims focus on changes that occur because your staff carry 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.

11. Job Aid: Process Mapping (pdf file)
    www.cpsi.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

12. Implementation Guide for the CANDOR Process | Agency for Healthcare Research and Quality
    www.cpsi.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

13. Leading Teams (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module4/ts2-0ltc_module4_slides_lead.pdf
    June 12, 2017 - nursing that the home develop a more effective plan for responding to resident emergencies that occur … In addition, because these events do not occur within a unit, but involve residents and staff from … s Performance: Debrief Process Improvement � Short information exchange and feedback sessions � Occur

14. Understand-Facilitator-Guide (doc file)
    www.cpsi.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.

15. Implementation Guide (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module11/ts2-0ltc_module11_impguide.pdf
    June 22, 2017 - ■ When and where will the improvements occur? … When will the training sessions occur and for how long? Where will the sessions occur?

16. 6 Tk1 T2-Talking With Residents Family Members Checklist Version Final (pdf file)
    www.cpsi.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

17. TeamSTEPPS 2.0 Quick Reference Guide to TeamSTEPPS Action Planning (pdf file)
    www.cpsi.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

18. TeamSTEPPS for Office-Based Care: Implementation Planning | Agency for Healthcare Research and Quality
    www.cpsi.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.

19. Selected Best Practices and Suggestions for Improvement (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d4i_pdi11-dehiscence-bestpractices.pdf
    May 17, 2016 - Recommended Practice: Conduct postoperative wound assessment • Documentation of the surgical wound should occur … 48 hours after surgery to establish a baseline.3-5 • Repeat assessment should occur every shift thereafter … Education should occur upon hire, annually, and when this protocol is added to job responsibilities.4

20. Understand the Science of Safety for Perinatal Safety (pdf file)
    www.cpsi.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.