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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50757/psn-pdf
    December 18, 2019 - psnet.ahrq.gov/issue/university-hospital-hounds-debtors-doctors-say-its-doing-harm Financial harms occur
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851464/psn-pdf
    July 19, 2023 - Impacts such as psychological health of the patient and access to care units, should a crash occur,
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/842432/psn-pdf
    January 11, 2023 - psnet.ahrq.gov/issue/medication-errors-year-review-january-through-december-2021 Medication errors continue to occur
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60924/psn-pdf
    September 16, 2020 - to support the focus of reporting initiatives on the system rather than individuals when failures occur
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46713/psn-pdf
    April 12, 2019 - The authors found that unsolicited patient complaints occur less frequently among older ophthalmologists
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838027/psn-pdf
    September 07, 2022 - advancing-anticoagulation-stewardship-playbook Warfarin and other anticoagulants are high-alert medications that, if errors occur
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852458/psn-pdf
    June 01, 2019 - patients to engage with their own safety and how to effectively communicate with patients should an error occur
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/847057/psn-pdf
    April 05, 2023 - This article discusses medication errors that continue to occur despite established practices that,
  9. pcmh.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
  10. pbrn.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
  11. www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruprev/factraining_slides.pptx
    December 01, 2014 - Nursing homes investigate adverse events after they occur. … Is it possible to intervene before adverse events occur? … Analysis: Reviews process for conducting investigations or root cause analyses when adverse events occur … When will the meeting occur? Which report(s) will be used at the meeting? … How will communication occur with other disciplines to confirm changes in care?
  12. preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruprev/factraining_slides.pptx
    December 01, 2014 - Nursing homes investigate adverse events after they occur. … Is it possible to intervene before adverse events occur? … Analysis: Reviews process for conducting investigations or root cause analyses when adverse events occur … When will the meeting occur? Which report(s) will be used at the meeting? … How will communication occur with other disciplines to confirm changes in care?
  13. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruprev/factraining_slides.pptx
    December 01, 2014 - Nursing homes investigate adverse events after they occur. … Is it possible to intervene before adverse events occur? … Analysis: Reviews process for conducting investigations or root cause analyses when adverse events occur … When will the meeting occur? Which report(s) will be used at the meeting? … How will communication occur with other disciplines to confirm changes in care?
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35152/psn-pdf
    July 13, 2005 - https://psnet.ahrq.gov/issue/not-what-doctor-ordered This article reports on the types of errors that occur
  15. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/ontime-preventablehospitaledvisits-overview.pptx
    May 01, 2017 - Nursing homes investigate adverse events after they occur. … Is it possible to intervene before adverse events occur? … Analysis: Reviews process for conducting investigations or root cause analyses when adverse events occur … When will the meeting occur? Which reports will be used at the meeting? … How will communication occur with other disciplines to confirm changes in care?
  16. preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/ontime-preventablehospitaledvisits-overview.pptx
    May 01, 2017 - Nursing homes investigate adverse events after they occur. … Is it possible to intervene before adverse events occur? … Analysis: Reviews process for conducting investigations or root cause analyses when adverse events occur … When will the meeting occur? Which reports will be used at the meeting? … How will communication occur with other disciplines to confirm changes in care?
  17. preventiveservices.ahrq.gov/sites/default/files/wysiwyg/hai/abate/faqs/faq-safety-chg-mupirocin.pdf
    March 01, 2022 - However, as with any product, side effects may occur. … Local CHG side effects are estimated to occur in 1–3 percent of patients.
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40971/psn-pdf
    June 01, 2012 - iatrogenic-psychological-harm This review discusses iatrogenic psychological harm, including how it may occur
  19. Four Moments Poster (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/four-moments/poster-one-option.pdf
    November 01, 2019 - Four Moments Poster AHRQ Pub. No. 17(20)-0028-EF November 2019 Moment 1 occurs at the time initiation of antibiotic therapy is considered: Ask, “Does my patient have an infection that requires antibiotics?” occurs when the dec…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35972/psn-pdf
    June 17, 2014 - https://psnet.ahrq.gov/issue/patient-safety-ed The authors discuss the kinds of errors that occur in