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101. Chapter 6. Discussion and Policy Implications | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/chapter6.html
     August 01, 2022 - indicated that the consumer perspective may be particularly important for patient safety events that occur … system features (often substantially removed from the consumer) that enabled a patient safety event to occur … attempt to both prevent patient safety events from occurring and understand the causes of events that do occur … This may particularly apply to patient safety events that occur in outpatient settings, where there is … Decisions regarding system functions/activities that occur at the "system hub" versus those that occur

102. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47291/psn-pdf
     October 31, 2018 - Little is known about the epidemiology of hospital suicides other than that they are rare and occur … Nationally, between 49 and 65 hospital suicides occur each year.

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

104. Creating a safer health care system: finding the constraint. | PSNet
     psnet.ahrq.gov/issue/creating-safer-health-care-system-finding-constraint
     February 24, 2011 - This theory asks the question of what should change, to what should it change, and how should change occur … Responses are framed with discussion of six thought processes that must occur at an organization for

105. Healthy Living: Infant Mortality | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/womenhealth/wm-hl.html
     September 01, 2015 - Approximately two-thirds of infant deaths occur in the neonatal period or within 1 month and one-third … occur in the postneonatal period from 1 month to less than 1 year.

106. AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/3.html
     December 01, 2017 - Static Week Calculation: Identify all weights that occur in the range of 170-190 days from the most … Static Week Calculation: Identify all weights that occur in the range of 85-95 days from the most … Static Week Calculation: Identify all weights that occur in the range of 25-35 days from the most … The Previous Weight does not need to occur in the week just prior to the most recent week.

107. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35927/psn-pdf
     February 17, 2011 - Healthcare Research and Quality–supported study discovered that claims without clear evidence of error do occur … On the other hand, the majority of expenditures toward litigation occur in cases of errors in which

108. Risk Assessment | Digital Healthcare Research
     digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/risk
     January 01, 2023 - mode and effects analysis (FMEA) is a method that attempts to identify all possible failures that can occur … developed, allowing the problems to either be avoided or a contingency plan to be in place should the error occur

109. Sensemakingnotes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/identify/sensemakingnotes.docx
     June 02, 2025 - . · The Learn from Defects Form, which provides a standardized means to assess where defects occur and … in that the failure mode and effects analysis searches for all possible ways in which an event could occur … These conditions are the mistakes that occur without human error. … failures are problems with physical items, such as equipment and software. · Organizational failures occur … By doing this, teams are able to assign meaning to the system breakdowns that occur on their units.

110. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45255/psn-pdf
     January 23, 2017 - Although most mistakes occur during the prescribing and transcribing stages, errors during the administration … process occur frequently as well.

111. Understand the Science of Safety for Perinatal Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-facilitator-guide.pdf
     May 01, 2017 - SAY: Errors occur within the health care setting because health care professionals are human, and … 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.

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

113. Selected Best Practices and Suggestions for Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4w_combo_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

114. Systems Approach | PSNet
     psnet.ahrq.gov/primer/systems-approach
     June 15, 2024 - The systems approach holds that efforts to catch human errors before they occur or block them from causing … Active errors almost always involve frontline personnel and occur at the point of contact between a human … In this construct, slips represent failures of schematic behaviors, or lapses in concentration, and occur … FMEA begins with identifying all the steps that must occur for a given process to occur.

115. Bar Coding for Patient Safety in Northern Michigan | Digital Healthcare Research
     digital.ahrq.gov/ahrq-funded-projects/bar-coding-patient-safety-northern-michigan
     January 01, 2023 - These events and errors occur at several places along the medication chain, including ordering medication … Order Entry) applications, but these approaches do nothing to correct the 34 percent of errors that occur

116. Urine a Tough Position | PSNet
     psnet.ahrq.gov/web-mm/urine-tough-position
     January 01, 2009 - Approximately 8%-9% of adverse events occur in physicians’ offices.( 1 ) Recent studies have examined … are ordered annually in primary care practices, yet little is known about how often laboratory errors occur … Because of improvements in and automation of laboratory procedures, most laboratory errors occur during … This patient verification should occur at the time a specimen is labeled, and the label should include … key issue is that outpatient clinics and labs should have methods to capture these errors when they occur

117. Provider risk factors for medication administration error alerts: analyses of a large-scale closed-loop medication administration system using RFID and barcode. | PSNet
     psnet.ahrq.gov/issue/provider-risk-factors-medication-administration-error-alerts-analyses-large-scale-closed-loop
     September 01, 2016 - Although most mistakes occur during the prescribing and transcribing stages, errors during the administration … process occur frequently as well.

118. Looking for Meds in All the Wrong Places | PSNet
     psnet.ahrq.gov/web-mm/looking-meds-all-wrong-places
     June 16, 2021 - As a result, medication errors occur regularly in the ED, ranging from about 5.4 to 16.1 medication errors … also need to be aware of high-alert medications, which can have catastrophic consequences if errors occur … Mistakes with medications occur not because a clinician has been incompetent by making an error, but … their own risks for medication errors, it is important to acknowledge that medication errors generally occur … Medication errors generally occur as a result of system failures rather than faults produced by particular

119. Do Transient Working Conditions Trigger Medical Errors? (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Grayson.pdf
     January 01, 2003 - whether transient changes in working conditions may precipitate errors or make errors more likely to occur … question, “Were exposures immediately preceding the case event different from those that typically occur … These events were less likely to occur during the 30 minutes preceding the error (OR = 0.14, 95% CI … the medical error than during the rest of the error shift, though they were more likely to occur on … Breaks from policy were significantly more likely to occur on the error shift but not during the 30

120. The pursuit of perfection: hospitals take heightened actions to reduce adverse events. | PSNet
     psnet.ahrq.gov/issue/pursuit-perfection-hospitals-take-heightened-actions-reduce-adverse-events
     November 18, 2020 - June 10, 2018 Tapping front-line knowledge: identifying problems as they occur helps … September 27, 2016 When errors occur.