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41. Sensemaking and Learn from Defects for Perinatal Safety (pdf file)
    www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.pdf
    May 01, 2017 - Defects 2 • The Learn From Defects Form, which provides a standardized means to assess where defects occur … These conditions are the mistakes that occur without human error. … • Organizational failures occur when decisional elements, such as culture, procedures, and leadership … By doing this, teams are able to assign meaning to the system breakdowns that occur on their L&D unit … defects on the L&D unit, it is important for staff to understand where and how breakdowns in safety occur

42. Sensemaking and Learn From Defects for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
    www.talkingquality.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-fac-guide.html
    July 01, 2023 - The Learn From Defects Form, which provides a standardized means to assess where defects occur and to … These conditions are the mistakes that occur without human error. … Organizational failures occur when decisional elements, such as culture,procedures, and leadership decisions … By doing this, teams are able to assign meaning to the system breakdowns that occur on their L&D unit … defects on the L&D unit, it is important for staff to understand where and how breakdowns in safety occur

43. TeamSTEPPS for Office-Based Care: Implementation Planning | Agency for Healthcare Research and Quality
    www.talkingquality.ahrq.gov/teamstepps/officebasedcare/module11/office_impplan.html
    September 01, 2015 - When and where will the improvements occur? … When will the training sessions occur and for how long? Where will the sessions occur?

44. TeamSTEPPS Fundamentals Course: Module 4. Leading Teams | Agency for Healthcare Research and Quality
    www.talkingquality.ahrq.gov/teamstepps/instructor/fundamentals/module4/igleadership.html
    March 01, 2019 - which information must be communicated, a leader must be clearly designated, and mutual support must occur … Did the items on this checklist occur? If not, what was not done? … When would the briefing occur? Who would be expected to attend? … In addition, information updates within the team should occur as often as necessary. … difficult to find time for such reviews in health care, TeamSTEPPS advocates that after action reviews occur

45. Pf-Engagement-Facilitator-Guide (doc file)
    www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/pf-engagement-facilitator-guide.docx
    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.

46. Health Care Simulation to Advance Safety | Agency for Healthcare Research and Quality
    www.talkingquality.ahrq.gov/research/findings/factsheets/errors-safety/simulproj15/index.html
    August 01, 2018 - mistakes safely, and to learn from these mistakes while avoiding patient harms that might otherwise occur … More focused forms of feedback with the guidance of an instructor are likely to occur during a debrief … clinicians' inquiries, they may evoke a wide range of emotional and behavioral characteristics that occur … Because of the uncertainty, complexity, and rapidly emerging conditions that occur in many health care … Given that unexpected events will occur, there are lessons to be learned regarding their anticipation

47. Module 4: Event Reporting, Event Investigation and Analysis | Agency for Healthcare Research and Quality
    www.talkingquality.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

48. Section 5, Table 3 (pdf file)
    www.talkingquality.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

49. 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.talkingquality.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 …

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

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

52. Appendix F: PowerPoint Presentation: Executive Summary | Agency for Healthcare Research and Quality
    www.talkingquality.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

53. Chapter 1: Background on Patient Safety and LEP Populations | Agency for Healthcare Research and Quality
    www.talkingquality.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

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

55. Engage Patients and Families for Perinatal Safety (pdf file)
    www.talkingquality.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.

56. Mod5-Disclosure-Checklist (pdf file)
    www.talkingquality.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

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

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

59. Module 7: Resolution | Agency for Healthcare Research and Quality
    www.talkingquality.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

60. Fall Prevention Toolkit (doc file)
    www.talkingquality.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