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41. 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.

42. 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

43. PSOPPC: Common Formats Hospital 2.0

    Research Study
    www.psoppc.org/psoppc_web/publicpages/commonFormatsHV2.0
    March 31, 2025 - Patient safety concerns for this category include only incidents that occur in a hospital.     … Patient safety concerns for this category include only incidents that occur in a hospital.     … Patient safety concerns for the VTE category include only incidents that occur in a hospital.     … Patient safety concerns for this category include only incidents that occur in a hospital.     … Patient safety concerns for this category include only incidents that occur in a hospital.    

44. 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

45. Read-Backs | PSNet
    psnet.ahrq.gov/taxonomy/term/3447
    Read-Backs When information is conveyed verbally, miscommunication may occur in a variety of ways, … especially when transmission may not occur clearly (e.g., by telephone or radio, or if communication

46. 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

47. 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

48. Introduction | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/reports/issue-briefs/maternal-mortality-1.html
    September 01, 2021 - 700 birthing people dying every year from pregnancy-related causes. 7 One-third of maternal deaths occur … The brief focuses on the maternal events that occur during childbirth and up to a week postpartum, with

49. 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
    May 19, 2016 - 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.

50. 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

51. TeamSTEPPS for Office-Based Care Implementation Workbook (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/officebasedcare/impworkbook.pdf
    December 11, 2015 - clinical subject matter  Understands the processes of care within workspace where changes will 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? … Write down the process steps as they currently occur and identify who is doing what, when, with what

52. TeamSTEPPS Fundamentals Course: Module 4 | Agency for Healthcare Research and Quality
    www.ahrq.gov/teamstepps/instructor/fundamentals/module4/exbriefing.html
    March 01, 2014 - When will the briefing occur?     Where will the briefing occur?    

53. TeamSTEPPS 2.0 Briefing Exercise Sheet (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module4/exbriefing.pdf
    March 20, 2014 - When will the briefing occur? iii. Where will the briefing occur? B.

54. Introduction | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/distributed-cognition-er-nurses1.html
    August 01, 2022 - References Each year, approximately 141 million emergency department (ED) visits occur

55. 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)

56. Briefing Exercise Sheet (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module4/ts2-0ltc_module4_briefing_exsheet.pdf
    April 24, 2017 - When will the briefing occur? iii. Where will the briefing occur? B.

57. 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

58. 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

59. Appendix, Develop a Flowchart of Your Current Medication Reconciliation Process | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/patient-safety/settings/hospital/match/appendix/app-5.html
    July 01, 2022 - When does reconciliation occur? … When does the followup occur? … When does the followup occur? … When does this occur? … When does the followup occur?

60. Appendix, Develop a Flowchart of Your Current Medication Reconciliation Process | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/patient-safety/settings/hospital/match/appendix/app-5.html
    July 01, 2022 - When does reconciliation occur? … When does the followup occur? … When does the followup occur? … When does this occur? … When does the followup occur?