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21. 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.

22. 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.

23. Co-Occurring Behavioral Health Conditions | The Academy
    integrationacademy.ahrq.gov/products/playbooks/opioid-use-disorder/implement-mat-for-oud/co-occurring-behavioral-health-conditions
    January 01, 2012 - underlying cause of overlapping symptoms. 1 Screening for mental health or substance use disorders may occur

24. 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

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. 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

27. Module 1: Communication and Optimal Resolution (CANDOR) Toolkit Module 1: An Overview of the CANDOR Process
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/module1-overview.pptx
    June 02, 2025 - 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 3rd and 4th components should occur simultaneously. … Let’s examine the specific activities that occur during the 4th component of the CANDOR process, Event … 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.

28. 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

29. 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

30. 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

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. Patient, Family Member, and Clinician Perceptions of Disclosure of Adverse Events in Labor and Delivery | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/reports/liability/baker.html
    August 01, 2017 - families in the care team and how to communicate with patients about the risks and mistakes that can occur … kinds of information should be disclosed regarding each event and explore how communication should occur … Second, we wanted to ascertain how patient and family and provider communication should occur to mitigate … Last, we interviewed 12 clinicians about the common failures that can occur leading to each event. … The highest level of agreement was for those failures that could occur during the Delivery phase for

33. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/60639/psn-pdf
    January 01, 2021 - 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. Kepner-Tregoe Matrix | Digital Healthcare Research
    digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/kepner-tregoe-matrix
    January 01, 2023 - ," "where does the problem occur?", "when does the problem occur?", "extent of shortcomings?" … DESCRIBE WHAT DID OR DOES OCCUR using the "is" column. … IDENTIFY CIRCUMSTANCES that could occur but do not recur using the "is not" column. 8.

35. Do falls and other safety issues occur more often during handovers when nurses are away from patients? Findings from a retrospective study design. | PSNet
    psnet.ahrq.gov/issue/do-falls-and-other-safety-issues-occur-more-often-during-handovers-when-nurses-are-away
    January 08, 2020 - Study Do falls and other safety issues occur more often during handovers when nurses … Do falls and other safety issues occur more often during handovers when nurses are away from patients … Do falls and other safety issues occur more often during handovers when nurses are away from patients

36. 066-Dec-Staff-Faqs-Safety-Side-Effects (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/066-dec-staff-faqs-safety-side-effects.docx
    October 01, 2024 - However, as with any product, side effects may occur. … Local CHG side effects are rare, estimated to occur in 1% to 3% of patients. … For example, this may occur if CHG enters the ear canal, and the patient has a perforated (punctured)

37. Interplay Between Cognitive Load and Diagnostic Accuracy | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-cognitive-load3.html
    May 01, 2024 - process information, and execute performance-based tasks effectively. 11 Although cognitive overload can occur … information overload, multitasking and interruptions, and environmental threats. 20 Information overload can occur … If clinicians cannot selectively engage with interruptions, cognitive overload will occur if too much … If extrinsic load is low, both type 1 and type 2 thinking can occur. … Conversely, if extrinsic load increases, as can occur with a chaotic environment, distractions, unsafe

38. Potential Problem Analysis | Digital Healthcare Research
    digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/potential-problem-analysis
    January 01, 2023 - When a problem may occur. When the schedule for the plan's completion is significant. … IDENTIFY SPECIFIC PROBLEMS that could occur and record them in the first column of a table. 3. … For each cause IDENTIFY PREVENTATIVE ACTIONS to prevent or reduce the likelihood that the cause will occur

39. Assessment of Pediatric Look-Alike, Sound-Alike Substitution Errors | Digital Healthcare Research
    digital.ahrq.gov/ahrq-funded-projects/assessment-pediatric-look-alike-sound-alike-substitution-errors
    January 01, 2023 - Health Care Theme Medication Errors Patient Safety Medication errors occur … LASA medication errors occur when a patient receives an incorrect medication because its name is spelled … practicing pediatricians evaluated LASA pairs identified in the literature, 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 … commonly used in pediatric ambulatory care and considered at high risk to patients should a substitution occur

40. Process Decision Program Chart | Digital Healthcare Research
    digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/process-decision-program-chart
    January 01, 2023 - developed, allowing the problems to either be avoided or a contingency plan to be in place should the error occur … each what-if element, BRAINSTORM POSSIBLE COUNTERMEASURES that could be implemented should the problem occur