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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
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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,
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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
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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
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psnet.ahrq.gov/node/46713/psn-pdf
April 12, 2019 - The authors found that unsolicited patient complaints occur less
frequently among older ophthalmologists
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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
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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
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psnet.ahrq.gov/node/847057/psn-pdf
April 05, 2023 - This article discusses medication errors
that continue to occur despite established practices that,
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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
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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
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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?
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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?
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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?
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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
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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?
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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?
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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.
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psnet.ahrq.gov/node/40971/psn-pdf
June 01, 2012 - iatrogenic-psychological-harm
This review discusses iatrogenic psychological harm, including how it may occur
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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…
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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