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61. NICU Family Information Packet, Appendix B, Sleep in Preterm Infants (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-sleep.pdf
    December 13, 2013 - – Sporadic motor movements may occur with low muscle tone between these movements.

62. Practice Facilitator Agenda - Lesson 2: Leading Teams and Situation Monitoring (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/officebasedcare/agenda-lesson2.pdf
    November 30, 2015 - Team Meetings (Briefs)  Where and when does planning occur for your team now?

63. Four Moments of Antibiotic Decision Making | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/antibiotic-use/long-term-care/four-moments/index.html
    August 01, 2021 - 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 …

64. Communication-Facilitator-Guide (doc file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/communication-facilitator-guide.docx
    June 01, 2021 - This can occur after someone has had antibiotics and can be devastating in nursing home residents. … 13 Case 3: Communication SAY: Let’s walk through a final case of communication errors that can occur … The nurse does not feel comfortable with this plan and knows that serious side effects can occur on antibiotics … Slide 16 Case 3 — DESC Script SAY: Conflict can occur in teams, and it is important to know how … to handle such situations when they occur.

65. Medication Discrepancies and Potential Adverse Drug Events During Transfer of Care from Hospital to Home | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/patient-safety/reports/liability/neumiller.html
    August 01, 2017 - Preventable adverse drug events (ADEs) have been shown to frequently occur in a variety of settings, … at least one medication discrepancy in the transition from hospital to home care, and discrepancies occur … costs were estimated to exceed $117 billion. 28 ADEs that are primarily the result of human errors occur … As discussed previously, preventable ADEs have been shown to occur frequently in a variety of settings … Conclusion Medication discrepancies frequently occur during the transition from hospital to home care

66. Suppl Pcmh-Items Cg-Cahps-Adult-Survey 2357-2A (doc file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/cg/instructions/suppl_pcmh-items_cg-cahps-adult-survey_2357-2a.docx
    March 11, 2016 - Some items cover events that occur with low frequency in the general population.

67. Engage Patients and Families for Perinatal Safety (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/pf-engagement-facilitator-guide.pdf
    May 01, 2017 - Slide 16 SAY: Adverse events occur when a patient is harmed as a result of receiving medical care … Rarely does an adverse event occur as a result of intent.

68. How To Implement the Pressure Injury Prevention Program in Your Organization
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module4/module4_pu-implementation_slides.pptx
    November 20, 2014 - Unit staff tell the Wound Care Team about high-risk patients or if skin problems occur. … 19 Practice Insight Staff Turnover 20 Communication Patterns Good communication needs to occur

69. Mod5-Disclosure-Checklist (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/mod5-disclosure-checklist.pdf
    April 01, 2016 - tool: Use Part I of the checklist to prepare for the initial disclosure conversation, which should occur

70. Strategy 2: Communicating for Improve Quality (Tool 1) (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy2/Strat2_Tool_1_Be_Partner_508.pdf
    May 24, 2013 - • Nurse shift changes occur when nurses who are going off duty share information about you with

71. AHRQ Safety Program for Perinatal Care: Be a Partner in Your Care (doc file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/supporting/partner-care.docx
    May 01, 2017 - · Nurse shift changes occur when nurses who are going off duty share information about you with nurses

72. Appendix B. Clinical Materials to Share With Primary Care Providers | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/patient-safety/settings/hospital/resource/nicu/packet/apb.html
    December 01, 2013 - UTI and urolithiasis do not occur any more frequently than in general population. … If the ductus is open at the time of hospital discharge, followup with a cardiologist should occur within … 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

73. Patient and Family Engagement for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/pf-engagement-fac-guide.html
    July 01, 2023 - Slide 17: Engaging After Adverse Events Say: Adverse events occur when a patient is harmed as a … Rarely does an adverse event occur as a result of intent.

74. Strategy 2: Communicating for Improve Quality (Tool 1) (doc file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy2/Strat2_Tool_1_Be_Partner_508.docx
    February 10, 2011 - Nurse shift changes occur when nurses who are going off duty share information about you with nurses

75. Module 7: Resolution | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes7.html
    August 01, 2022 - Slide 1 Say: When adverse patient events occur, the patient and their family are looking for

76. Fall Prevention Toolkit (doc file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module5/module5_tools.docx
    August 03, 2017 - Ensure timescales for assessing and preventing falls are tailored to when falls are most likely to occur … Observations at the bedside should occur at the time of day when most patients who are well enough would

77. 10 Patient Safety Tips for Hospitals | Agency for Healthcare Research and Quality
    www.cpsi.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 … minute DVD provides video excerpts of 50 actual chest tube insertions to illustrate problems that can occur

78. Saving Lives and Saving Money: Hospital-Acquired Conditions Update | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/hai/pfp/2014-final.html
    January 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 …

79. Patient and Family Engagement | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/hai/cusp/modules/patient-family-engagement/notes.html
    September 01, 2013 - Introduction to Adverse Events Say: Adverse events occur when a patient is harmed as a result of … Rarely does an adverse event occur as a result of intent.

80. NPSD Data Spotlight - Patient Safety and COVID-19: A Qualitative Analysis of Concerns During the Public Health Emergency (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-ptsafety-and-covid-19.pdf
    November 01, 2021 - Many areas for errors to occur especially with increase in test volume. … These policy- and procedure-related events are more likely to occur in a rapidly changing environment