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81. Event Investigation and Analysis Guide: Appendix D | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apd.html
    August 01, 2022 - Could this type of communication failure occur in the future during normal working conditions? … Why did they occur? Is there any opportunity to overcome the barriers?

82. System-Focused Event Investigation and Analysis Guide | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4.html
    August 01, 2022 - In addition, learning about system vulnerabilities before they occur is critical. … The CANDOR Response Team is responsible for conducting a preliminary review, which should occur within … The preliminary review should occur at the event location. … understanding of the event: if individual interviews, appropriate information gathering, and observations occur … Please note that the bulk of the time and effort of the event review process should occur during the

83. Module 3: Script and Slides (doc file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/problem-solving/problem-solving-facnotes.docx
    May 01, 2017 - She will know that it is successful when fewer similar problems occur. … remind you that there are resources to facilitate escalation of critical, safety-related issues that may occur

84. NICU Family Information Packet, Appendix B, Ostomy Care (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-ostomy.pdf
    December 13, 2013 - ■ Fungal infections: can occur in the warm, moist environment beneath the barrier and erode skin

85. National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data From National Efforts To Make Health Care Safer | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/hai/pfp/2015-interim.html
    December 01, 2016 - 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 …

86. NICU Family Information Packet, Appendix B, Anemia of Prematurity (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-anemia.pdf
    December 13, 2013 - NICU Family Information Packet, Appendix B, Anemia of Prematurity Anemia Of Prematurity Characteristics ■ Occurs during the normal developmental switch from fetal to adult hemoglobin synthesis. ■ Immediately after birth, the increase in blood oxygen content results in the downregulation of erythropoietin. ■ On…

87. Saving Lives and Saving Money: Hospital-Acquired Conditions Update - Interim Data From National Efforts To Make Care Safer, 2010-2014 (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/publications/files/interimhacrate2014_2.pdf
    November 19, 2015 - Saving Lives and Saving Money: Hospital-Acquired Conditions Update - Interim Data From National Efforts To Make Care Safer, 2010-2014 Saving Lives and Saving Money: Hospital-Acquired Conditions Update Interim Data From National Efforts To Make Care Safer, 2010-2014 Summary Interim estimates for 2014 show a s…

88. Final Data From National Efforts To Make Care Safer, 2010-2014 (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/2014FinalHACreport4Web-13Dec2016.pdf
    December 01, 2016 - Final Data From National Efforts To Make Care Safer, 2010-2014 December 2016 Saving Lives and Saving Money: Hospital-Acquired Conditions Update Final Data From National Efforts To Make Care Safer, 2010-2014 Summary Final estimates for 2014 show a sustained 17 percent decline in hospital-acquired conditions…

89. CAHPS (doc file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/cg/instructions/suppl_pcmh_items_cg-cahps-child-survey_2358-2a.docx
    March 11, 2016 - Some items cover events that occur with low frequency in the general population.

90. PRIMARY CARE OFFICE-BASED TEAMS Leading Teams
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/officebasedcare/module4/4_ts_office_leading-ig.pptx
    January 20, 2006 - Followup questions: When and where does planning occur for you now? Who attends? … Sample some responses, and then emphasize that updates should occur as often as necessary, particularly

91. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/vae/objective-outcome-tool.docx
    January 01, 2017 - Facilitator Guide: Build Your SSI Prevention Bundle Hospital ___________ Unit___________ Month ___________ Please record the following occurrences for all patients in your unit within the selected month. ________ Total number of patients on mechanical ventilation ________ Total number of episodes of mechani…

92. Selected Best Practices and Suggestions for Improvement (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4n_combo_iqi-mortalityreview-bestpractices.pdf
    May 20, 2016 - community and the public on the estimation that between 48,000 and 98,000 deaths from medical errors occur …  Yes:  Did any of the following occur during hospitalization? …  Yes:  Did any of the following occur during the hospitalization (check all that apply) ∗ Death

93. Applying the AHRQ Quality Indicators to Hospital Data (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/b1_combo_applyingqis.pdf
    March 01, 2016 - that specific indicator Expected events = for each QI indicator, the total sum of events expected to occur … by the size of your hospital’s patient population and the types of quality and safety events that occur … eligible hospital stay is assigned an expected probability that a particular indicator event will occur

94. Module 4: Teamwork and Communication: Facilitator Notes | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module4/mod4-facguide.html
    March 01, 2017 - Slide 17: For Information Transfer – Handoffs Say: Handoffs occur during a change in assignment … A handoff may occur when a resident is first welcomed to the nursing home from the hospital or during … another staff member, even for a short timespan such as a lunch break, a structured communication should occur

95. Measure Descriptions for Daily Early Mobility: Facilitator Guide | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/hai/tools/mvp/modules/technical/daily-early-mobility-fac-guide.html
    February 01, 2017 - measurement, it’s recommended to choose the value closest to 10 a.m. because this is usually when rounds occur … performed, it’s recommended to choose the value closest to 10 a.m. because this is usually when rounds occur

96. Transitioning Newborns from NICU to Home: Family Information Packet, Appendix B (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb.pdf
    December 10, 2013 - ■ UTI and urolithiasis do not occur any more frequently than in general population. … – Earlier followup should occur if poor weight gain, difficulty feeding, and tachypnea develop. … ■ Fungal infections: can occur in the warm, moist environment beneath the barrier and erode skin … – Sporadic motor movements may occur with low muscle tone between these movements. … ■ Tracheo-esophageal fistula may occur as a result of posterior wall erosion.

97. AHRQ Papers on Diagnostic Safety Topics | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/patient-safety/reports/dxsafety-issuebriefs.html
    January 01, 2024 - Resources AHRQ Papers on Diagnostic Safety Topics Diagnostic errors occur

98. NICU Family Information Packet, Appendix B, Growth (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-growth.pdf
    December 13, 2013 - NICU Family Information Packet, Appendix B, Growth Growth General Growth ■ Use growth charts made specifically for premature infants. ■ After infant reaches term corrected gestational age, a standard growth chart may be used. ■ Use corrected postmenstrual age until 2 years of age. ■ Interpretations of catch-u…

99. Summary Skills Practice Exercise Sheet (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module7/ts2-0ltc_module7_ig_summary_exsheet.pdf
    April 24, 2017 - Summary Skills Practice Exercise Sheet Summary Summary Skills Practice Exercise Sheet INSTRUCTIONS: 1. Break into four small groups. Each group will receive one of four teamwork skill handouts. 2. Read the scenario below. 3. Identify the instances where a breakdown in teamwork has occurred as it rel…

100. Playbook for Preventing CLABSI and CAUTI in the ICU Setting | Agency for Healthcare Research and Quality
     www.cpsi.ahrq.gov/hai/tools/clabsi-cauti-icu/implement/playbook.html
     April 01, 2022 - CUSP can be implemented through CLABSI and CAUTI prevention practices, policies, and procedures that occur