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41. Module 4: Event Reporting, Event Investigation and Analysis | Agency for Healthcare Research and Quality
    www.innovations.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes4.html
    August 01, 2022 - Within the first 72 hours of a CANDOR event, the following actions should occur: Schedule and complete

42. Section 5, Table 3 (pdf file)
    www.innovations.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-229-section-5-table-3.pdf
    August 01, 2014 - Because rapid sterilization of blood cultures can occur within a few hours after the first antimicrobial … Sampling before antibiotic therapy is important, because sterilization of blood cultures can occur

43. 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013 | Agency for Healthcare Research and Quality
    www.innovations.ahrq.gov/hai/pfp/hacrate2013.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 …

44. Practice Facilitator Agenda - Lesson 2: Leading Teams and Situation Monitoring (pdf file)
    www.innovations.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?

45. Four Moments of Antibiotic Decision Making | Agency for Healthcare Research and Quality
    www.innovations.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 …

46. Appendix F: PowerPoint Presentation: Executive Summary | Agency for Healthcare Research and Quality
    www.innovations.ahrq.gov/health-literacy/professional-training/lepguide/app-f.html
    September 01, 2020 - engage in a systematic approach to better identify and prevent medical errors and adverse events that occur … patient safety among LEP patients, as well as processes to analyze medical errors and near misses that occur … among LEP patients Create routine forums for analyzing cases of medical errors and near misses that occur … engage in a systematic approach to better identify and prevent medical errors and adverse events that occur

47. Chapter 1: Background on Patient Safety and LEP Populations | Agency for Healthcare Research and Quality
    www.innovations.ahrq.gov/health-literacy/professional-training/lepguide/chapter1.html
    September 01, 2020 - Medical errors can occur anywhere in the health care system: hospitals, clinics, outpatient surgery centers … event" refers to a particularly shocking medical error (such as wrong-site surgery) that should never occur … LEP patients are more likely than English-speaking patients to suffer from physical harm when errors occur … situations, which we call high-risk scenarios, where adverse events and medical errors are most likely to occur … 6 shows examples from actual patient safety reports that illustrate the delays and errors that can occur

48. Medication Discrepancies and Potential Adverse Drug Events During Transfer of Care from Hospital to Home | Agency for Healthcare Research and Quality
    www.innovations.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

49. Engage Patients and Families for Perinatal Safety (pdf file)
    www.innovations.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.

50. How To Implement the Pressure Injury Prevention Program in Your Organization
    www.innovations.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

51. Mod5-Disclosure-Checklist (pdf file)
    www.innovations.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

52. AHRQ Safety Program for Perinatal Care: Be a Partner in Your Care (doc file)
    www.innovations.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

53. Patient and Family Engagement for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
    www.innovations.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.

54. Module 7: Resolution | Agency for Healthcare Research and Quality
    www.innovations.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

55. Fall Prevention Toolkit (doc file)
    www.innovations.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

56. Saving Lives and Saving Money: Hospital-Acquired Conditions Update | Agency for Healthcare Research and Quality
    www.innovations.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 …

57. Patient and Family Engagement | Agency for Healthcare Research and Quality
    www.innovations.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.

58. Event Investigation and Analysis Guide: Appendix D | Agency for Healthcare Research and Quality
    www.innovations.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?

59. System-Focused Event Investigation and Analysis Guide | Agency for Healthcare Research and Quality
    www.innovations.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

60. Module 3: Script and Slides (doc file)
    www.innovations.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