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21. What is workflow? | Digital Healthcare Research
    digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/workflow
    January 01, 2023 - It can occur at several levels (one person, between people, across organizations) and can occur sequentially … implementations demonstrates that delays in patient care, billing, and communication are likely to occur

22. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/41989/psn-pdf
    September 27, 2016 - Tapping front-line knowledge: identifying problems as they occur helps enhance patient safety. … Tapping front-line knowledge: identifying problems as they occur helps enhance patient safety. … https://psnet.ahrq.gov/issue/tapping-front-line-knowledge-identifying-problems-they-occur-helps-enhance … https://psnet.ahrq.gov/issue/tapping-front-line-knowledge-identifying-problems-they-occur-helps-enhance-patient-safety … https://psnet.ahrq.gov/issue/tapping-front-line-knowledge-identifying-problems-they-occur-helps-enhance-patient-safety

23. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/34607/psn-pdf
    June 12, 2018 - A clinician's guide to surgical fires: how they occur, how to prevent them, how to put them out. … How they occur, how to prevent them, how to put them out. Health Devices. 2003;32(1):5-24. … https://psnet.ahrq.gov/issue/clinicians-guide-surgical-fires-how-they-occur-how-prevent-them-how-put- … https://psnet.ahrq.gov/issue/clinicians-guide-surgical-fires-how-they-occur-how-prevent-them-how-put-them-out … https://psnet.ahrq.gov/issue/clinicians-guide-surgical-fires-how-they-occur-how-prevent-them-how-put-them-out

24. Fatal 1,000-fold overdoses can occur, particularly in neonates, by transposing mcg and mg. | PSNet
    psnet.ahrq.gov/issue/fatal-1000-fold-overdoses-can-occur-particularly-neonates-transposing-mcg-and-mg
    June 10, 2018 - Newspaper/Magazine Article Fatal 1,000-fold overdoses can occur, particularly in … Citation Text: Fatal 1,000-fold overdoses can occur, particularly in neonates, by transposing mcg and … Cite Citation Citation Text: Fatal 1,000-fold overdoses can occur

25. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/39252/psn-pdf
    August 08, 2010 - Where errors occur in the preparation and administration of intravenous medicines: a systematic review … Where errors occur in the preparation and administration of intravenous medicines: a systematic review … https://psnet.ahrq.gov/issue/where-errors-occur-preparation-and-administration-intravenous-medicines- … medication errors, a significant proportion of errors are not due to incorrect prescribing, but instead occur … https://psnet.ahrq.gov/issue/where-errors-occur-preparation-and-administration-intravenous-medicines-systematic-review-and

26. NICU Family Information Packet, Appendix B, Patent Ductus Arteriosus (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-pda.pdf
    December 13, 2013 - ■ If the ductus is open at the time of hospital discharge, followup with a cardiologist should occur … – Earlier followup should occur if poor weight gain, difficulty feeding, and tachypnea develop. … Management ■ If spontaneous closure does not occur, closure should be performed to: – Eliminate pulmonary

27. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/39961/psn-pdf
    March 08, 2015 - When errors occur. March 8, 2015 Wetzel TG. … When errors occur, 'I'm sorry' is a big step, but just the first. … https://psnet.ahrq.gov/issue/when-errors-occur This article describes how hospital responses to adverse … https://psnet.ahrq.gov/issue/when-errors-occur https://psnet.ahrq.gov/issue/liability-claims-and-costs-and-after-implementation-medical-error-disclosure-program

28. Tapping front-line knowledge: identifying problems as they occur helps enhance patient safety. | PSNet
    psnet.ahrq.gov/issue/tapping-front-line-knowledge-identifying-problems-they-occur-helps-enhance-patient-safety
    July 21, 2009 - Newspaper/Magazine Article Tapping front-line knowledge: identifying problems as they occur … Tapping front-line knowledge: identifying problems as they occur helps enhance patient safety. … Tapping front-line knowledge: identifying problems as they occur helps enhance patient safety.

29. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/38992/psn-pdf
    April 16, 2018 - Safe patient outcomes occur with timely, standardized communication of critical values. … April 16, 2018 https://psnet.ahrq.gov/issue/safe-patient-outcomes-occur-timely-standardized-communication-critical … https://psnet.ahrq.gov/issue/safe-patient-outcomes-occur-timely-standardized-communication-critical-values … https://psnet.ahrq.gov/issue/safe-patient-outcomes-occur-timely-standardized-communication-critical-values

30. Module 1: An Overview of the CANDOR Process | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes1.html
    August 01, 2022 - This table demonstrates just a few of the changes that must occur to realize the goals of the CANDOR … After the CANDOR System Activation occurs, the 3 rd and 4 th components should occur simultaneously … The following activities should occur at this time: the Core Team will schedule and complete interviews … The second part should occur within 30-45 business days after a CANDOR event has been identified. … Resolution of the event can only occur after Event Investigation and Analysis has been completed.

31. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/37196/psn-pdf
    June 06, 2018 - Fatal 1,000-fold overdoses can occur, particularly in neonates, by transposing mcg and mg. … https://psnet.ahrq.gov/issue/fatal-1000-fold-overdoses-can-occur-particularly-neonates-transposing-mcg … https://psnet.ahrq.gov/issue/fatal-1000-fold-overdoses-can-occur-particularly-neonates-transposing-mcg-and-mg … https://psnet.ahrq.gov/issue/fatal-1000-fold-overdoses-can-occur-particularly-neonates-transposing-mcg-and-mg

32. Action Planning Worksheets | Agency for Healthcare Research and Quality
    www.ahrq.gov/teamstepps/instructor/essentials/implguide2.html
    November 01, 2018 - Understands the processes of care within workspace where changes will occur. … When does the "problem" occur? … When will the improvement occur? Within what timeframe?   … When will the improvement occur? Within what timeframe?   … When will the improvement occur? Within what timeframe?  

33. Economic analysis of the prevalence and clinical and economic burden of medication error in England. | PSNet
    psnet.ahrq.gov/issue/economic-analysis-prevalence-and-clinical-and-economic-burden-medication-error-england
    April 17, 2024 - The authors estimate that 237 million medication errors occur annually in the UK. … The majority of errors occur during medication administration and prescribing and occur most frequently

34. 20 Tips To Help Prevent Medical Errors: Patient Fact Sheet | Agency for Healthcare Research and Quality
    www.ahrq.gov/questions/resources/20-tips.html
    November 01, 2020 - 20 Tips To Help Prevent Medical Errors: Patient Fact Sheet Medical errors can occur … But medical errors can occur anywhere in the health care system: In hospitals, clinics, surgery centers … What do I do if they occur?

35. Review of medication errors that are new or likely to occur more frequently with electronic medication management systems. | PSNet
    psnet.ahrq.gov/issue/review-medication-errors-are-new-or-likely-occur-more-frequently-electronic-medication
    August 18, 2021 - Study Review of medication errors that are new or likely to occur more frequently … Review of medication errors that are new or likely to occur more frequently with electronic medication … Review of medication errors that are new or likely to occur more frequently with electronic medication

36. TeamSTEPPS for Office-Based Care: Implementation Workbook | Agency for Healthcare Research and Quality
    www.ahrq.gov/teamstepps/officebasedcare/impworkbook.html
    December 01, 2015 - Understands the processes of care within workspace where changes will occur. … When does the "problem" occur? … When will the improvement occur? Within what timeframe?   … When will the improvement occur? Within what timeframe?   … When will the improvement occur? Within what timeframe?    

37. Adverse Drug Events occurring in U.S. Hospitals (pdf file)
    pcmh.ahrq.gov/sites/default/files/wysiwyg/data/infographics/adverse-drug-events.pdf
    July 02, 2015 - Hospitals Adverse drug events (ADEs) are the most common nonsurgical adverse events that occur in hospitals

38. Adverse Drug Events occurring in U.S. Hospitals (pdf file)
    pbrn.ahrq.gov/sites/default/files/wysiwyg/data/infographics/adverse-drug-events.pdf
    July 02, 2015 - Hospitals Adverse drug events (ADEs) are the most common nonsurgical adverse events that occur in hospitals

39. Adverse Drug Events occurring in U.S. Hospitals (pdf file)
    cahps.ahrq.gov/sites/default/files/wysiwyg/data/infographics/adverse-drug-events.pdf
    July 02, 2015 - Hospitals Adverse drug events (ADEs) are the most common nonsurgical adverse events that occur in hospitals

40. Making Pediatric Care Safer and Higher Quality | Agency for Healthcare Research and Quality
    www.ahrq.gov/funding/grantee-profiles/grtprofile-rinke.html
    December 01, 2019 - Rinke’s research revealed that CLABSIs occur three times more frequently in ambulatory settings than … funding to conduct multisite epidemiological studies focused on healthcare-associated infections that occur … Preliminary data suggest that CLABSIs occur at comparable rates in inpatient and ambulatory settings. … He found that diagnostic errors and missed opportunities for diagnosis occur often in pediatric primary