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

62. Patient and Family Engagement | Agency for Healthcare Research and Quality
    www.talkingquality.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.

63. NPSD Data Spotlight - Patient Safety and COVID-19: A Qualitative Analysis of Concerns During the Public Health Emergency (pdf file)
    www.talkingquality.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

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

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

66. Module 3: Script and Slides (doc file)
    www.talkingquality.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

67. 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.talkingquality.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 …

68. Follow-up Visits for Children Who Are Obese or Overweight with a Weight-Related Comorbidity: Technical Specifications (pdf file)
    www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-0242-technicalspecs.pdf
    February 04, 2020 - This subsequent visit in which weight was addressed could occur in various settings: with a primary

69. IMPLEMENT California Asthma QI Collaborative (pdf file)
    www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/pqmp/toolkits/sfmeasures.pdf
    March 03, 2021 - The education could occur during a structured phone follow-up call.

70. Final Data From National Efforts To Make Care Safer, 2010-2014 (pdf file)
    www.talkingquality.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…

71. Chipra205-Materials Iiia (pdf file)
    www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/CHIPRA205-Materials_IIIA.pdf
    January 01, 2014 - Organizations may count services that occur over multiple visits toward this measure as long as all … of the services occur within the time frame established in the measure.

72. Chipra204-Materials Iiia (pdf file)
    www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/CHIPRA204-Materials_IIIA.pdf
    January 01, 2014 - Organizations may count services that occur over multiple visits toward this measure as long as all … of the services occur within the time frame established in the measure.

73. Chipra202-Materials Iiia (pdf file)
    www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/CHIPRA202-Materials_IIIA.pdf
    January 01, 2014 - Organizations may count services that occur over multiple visits toward this measure as long as all … of the services occur within the time frame established in the measure.

74. PRIMARY CARE OFFICE-BASED TEAMS Leading Teams
    www.talkingquality.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

75. Selected Best Practices and Suggestions for Improvement (pdf file)
    www.talkingquality.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

76. Applying the AHRQ Quality Indicators to Hospital Data (pdf file)
    www.talkingquality.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

77. Module 4: Teamwork and Communication: Facilitator Notes | Agency for Healthcare Research and Quality
    www.talkingquality.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

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

79. AHRQ Quality and Safety Review System (QSRS) | Agency for Healthcare Research and Quality
    www.talkingquality.ahrq.gov/patient-safety/quality-measures/qsrs/index.html
    September 01, 2022 - Medicine report, To Err Is Human , revealed more than 15 years ago the extent of medical errors that occur

80. Silence A Commentary | Agency for Healthcare Research and Quality
    www.talkingquality.ahrq.gov/patient-safety/reports/liability/silence.html
    August 01, 2017 - Yet, when harm does occur, and honest and transparent conversations are not conducted, you harm us again