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1. Module 1: An Overview of the CANDOR Process | Agency for Healthcare Research and Quality
   www.innovations.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. Action Planning Worksheets | Agency for Healthcare Research and Quality
   www.innovations.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?  

3. TeamSTEPPS for Office-Based Care: Implementation Workbook | Agency for Healthcare Research and Quality
   www.innovations.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?    

4. TeamSTEPPS for Office-Based Care Implementation Workbook (pdf file)
   www.innovations.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

5. 20 Tips To Help Prevent Medical Errors: Patient Fact Sheet | Agency for Healthcare Research and Quality
   www.innovations.ahrq.gov/questions/resources/20-tips.html
   November 01, 2020 - 20 Tips To Help Prevent Medical Errors: Patient Fact Sheet Medical errors can occur … But medical errors can occur anywhere in the health care system: In hospitals, clinics, surgery centers … What do I do if they occur?

6. The Ten Steps of Action Planning  | Agency for Healthcare Research and Quality
   www.innovations.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.

7. Job Aid: Process Mapping (pdf file)
   www.innovations.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

8. Implementation Guide for the CANDOR Process | Agency for Healthcare Research and Quality
   www.innovations.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

9. 6 Tk1 T2-Talking With Residents Family Members Checklist Version Final (pdf file)
   www.innovations.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

10. TeamSTEPPS 2.0 Quick Reference Guide to TeamSTEPPS Action Planning (pdf file)
    www.innovations.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

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

12. Selected Best Practices and Suggestions for Improvement (pdf file)
    www.innovations.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

13. Office-Based Teams Instructor Guide
    www.innovations.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/officebasedcare/module11/11_ts_office_impplan-ig.pptx
    January 20, 2006 - Write down the process steps as they currently occur and identify who is doing what, when, and with what … 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 what … Who will attend the training sessions; What skills you will teach; When the training sessions will occur … and for how long; Where the sessions will occur; How you will train (method of presentation, tools,

14. Adverse Drug Events Occurring in U.S. Hospitals | Agency for Healthcare Research and Quality
    www.innovations.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 …

15. Advancing Diagnostic Safety: An AHRQ Leadership Conversation | Agency for Healthcare Research and Quality
    www.innovations.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

16. Using Patient Input to Improve Diagnostic Safety | Agency for Healthcare Research and Quality
    www.innovations.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

17. Applying a Novel Organization Change Scale in a Multisite Patient Safety Initiative | Agency for Healthcare Research and Quality
    www.innovations.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

18. Chapter 2: Five Key Recommendations To Improve Patient Safety for LEP Patients | Agency for Healthcare Research and Quality
    www.innovations.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.

19. Understand the Science of Safety for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
    www.innovations.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.

20. Surge in Drug Shortages Occurred in Wake of Pandemic, Study Finds | Agency for Healthcare Research and Quality
    www.innovations.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 …