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161. Addressing Workplace Violence and Creating a Safer Workplace | PSNet
     psnet.ahrq.gov/perspective/addressing-workplace-violence-and-creating-safer-workplace
     October 31, 2023 - tagged PubMedId RIS Download Citation While violence in the workplace can occur … stalking, and sexual harassment. 5 Perpetrators of workplace violence can vary, and violence can occur … we think that certain units may have a patient population that may predispose workplace violence to occur … In recent years, in addition to workplace violence events that may occur in healthcare organizations, … Having reporting systems in place that facilitate the reporting of events when they actually occur is

162. In Conversation with... Cheryl Jones about Addressing Workplace Violence and Creating a Safer Workplace | PSNet
     psnet.ahrq.gov/perspective/conversation-cheryl-jones-about-addressing-workplace-violence-and-creating-safer
     October 31, 2023 - employ large numbers of healthcare professionals, with opportunities for workplace violence events to occur … we think that certain units may have a patient population that may predispose workplace violence to occur … In recent years, in addition to workplace violence events that may occur in healthcare organizations, … challenges with reporting and making it easier for clinicians to report acts of violence when they occur … Having reporting systems in place that facilitate the reporting of events when they actually occur is

163. Pressure Ulcer Prevention Toolkit (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module4/putoolkit_module4_tools.docx
     January 01, 1995 - Friction may occur when moving a person up in bed. 43. … For persons who have incontinence, skin cleaning should occur at the time of soiling and at routine intervals … Friction may occur when moving a person up in bed. True 43. … For persons who have incontinence, skin cleaning should occur at the time of soiling and at routine intervals

164. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/837708/psn-pdf
     July 20, 2022 - psnet.ahrq.gov/issue/without-question Diagnostic errors caused by premature closure and anchoring bias occur

165. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/factraining.html
     September 01, 2017 - Communicate risk changes as they occur. … Improve root cause analyses when adverse events occur. … When will the meeting occur? … How will communication occur with other disciplines to confirm changes in care? … When will the meeting occur?

166. Assessment of Pediatric Look-Alike, Sound-Alike (LASA) Substitution Errors - Final Report (pdf file)
     digital.ahrq.gov/sites/default/files/docs/publication/r03hs018841-basco-final-report-2013.pdf
     January 01, 2013 - Scope: Medication errors occur frequently in ambulatory prescribing, but less is known about the potential … Methods: 37 practicing pediatricians evaluated published LASA pairs, estimating the harm that might occur … should a patient not receive the intended drug in any LASA pair and the harm that might occur from … However, the substitutions can occur in either direction, meaning that there are actually 3568 pairs … The instructions reminded participants to not estimate the chance that harm would occur.

167. Sensemaking and Learn from Defects for Perinatal Safety (pdf file)
     www.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

168. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/865598/psn-pdf
     April 17, 2024 - medication therapy for transplant patients is complex and has the potential for serious harm when errors occur

169. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/72911/psn-pdf
     March 15, 2021 - nutritional supplements are often overlooked by providers and patients.7     Medication errors may occur … Hospital discharges are one example of a transition of care, and over 35 million hospital discharges occur … The Joint Commission Center for Transforming Healthcare reports that communication breakdowns occur … Breakdowns in patient education can occur when conflicting recommendations are made. … Accountability breakdowns occur when there is no primary provider to take responsibility for assuring

170. Around the Block | PSNet
     psnet.ahrq.gov/web-mm/around-block
     March 04, 2020 - And, perhaps most importantly, how did this series of events occur despite the presence of the warning … Preoperative LMWH Needle placement should occur at least 10-12 hours after the LMWH dose. … avoided in patients administered a dose of LMWH 2 hours preoperatively, because needle placement would occur … The second postoperative dose should occur no sooner than 24 hours after the first dose. … Subsequent LMWH dosing should occur a minimum of 2 hours after catheter removal.

171. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49476/psn-pdf
     March 02, 2005 - And, perhaps most importantly, how did this series of events occur despite the presence of the warning … list_uids=11342094 https://psnet.ahrq.gov//#references Preoperative LMWH Needle placement should occur … avoided in patients administered a dose of LMWH 2 hours preoperatively, because needle placement would occur … The second postoperative dose should occur no sooner than 24 hours after the first dose. … Subsequent LMWH dosing should occur a minimum of 2 hours after catheter removal.

172. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45611/psn-pdf
     May 27, 2025 - funding-announcement-projects-targeting-reduction-healthcare-associated- infections Health care–associated infections occur

173. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867224/psn-pdf
     December 04, 2024 - safety-inpatient-care-surgical-settings-cohort-study Despite decades of safety improvement efforts, surgical complications continue to occur

174. The How-To’s of Hand Hygiene | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/education-bundles/infection-prevention/hand-hygiene/hand-hygiene-slides.html
     March 01, 2017 - 3: Health Care Workers' Hands Spread Infections 1 1-3 million serious infections estimated to occur … Hand contamination may occur as a result of small undetected holes in gloves. … Hand contamination may occur during glove removal.

175. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/861776/psn-pdf
     January 31, 2024 - such as communication and resolution programs to encourage apologies and transparency when errors occur

176. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49485/psn-pdf
     August 29, 2024 - Though not well appreciated by many clinicians, POVL may occur in relatively healthy patients, even when … AION has been associated primarily with cardiac bypass procedures but can occur during prone spine operations … Peripheral vision is frequently affected, but total blindness may occur as well. … Visual loss secondary to AION has been reported to occur anytime from the immediate postoperative period … count fingers does not preclude the possibility of scotoma or discrete visual field deficits as may occur

177. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867696/psn-pdf
     March 05, 2025 - are a core strategy to ensure safe care for hospitalized patients should unexpected deterioration occur

178. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/72484/psn-pdf
     November 18, 2020 - focuses on management of, and preparation for, perioperative critical events and rescue should they occur

179. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/841199/psn-pdf
     December 07, 2022 - houses collections of materials to support constructive communication should a failure or near-miss occur

180. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/851927/psn-pdf
     August 02, 2023 - https://psnet.ahrq.gov/issue/perioperative-handoffs Handoffs occur several times during a surgical procedure