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61. Appendix, Develop a Flowchart of Your Current Medication Reconciliation Process | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.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?

62. Learn From Defects in Care of Mechanically Ventilated Patients: Slide Presentation | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/mvp/modules/cusp/learn-from-defects-slides.html
    February 01, 2017 - List contributing factors that make defects in care more likely to occur. … Why 1—Why did this contributing factor occur? Why 2—Why did “Why 1” occur? … Why 3—Why did “Why 2” occur? Why 4—Why did “Why 3” occur? Why 5—Why did “Why 4” occur? … Does it occur rarely or have a high likelihood of reoccurring?

63. Module 1: An Overview of the CANDOR Process | Agency for Healthcare Research and Quality
    pbrn.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.

64. Module 1: An Overview of the CANDOR Process | Agency for Healthcare Research and Quality
    pcmh.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.

65. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/46827/psn-pdf
    March 14, 2018 - Prior research has shown that medication errors occur frequently and are associated with a longer hospital … The authors estimate that 237 million medication errors occur annually and that 66 million of these … The majority of potentially harmful errors likely occur in the outpatient setting where most medications

66. Presentation: Program Overview
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/learn-from-defects-slides.pptx
    January 01, 2017 - and second-order problem solving List contributing factors that make defects in care more likely to occur … you identify contributing factors Use the “5 Whys” technique Why 1—Why did this contributing factor occur … Why 2—Why did “Why 1” occur? Why 3—Why did “Why 2” occur? Why 4—Why did “Why 3” occur? … Why 5—Why did “Why 4” occur? … Does it occur rarely or have a high likelihood of reoccurring?

67. Acute Care Asymptomatic Bacteriuria and Urinary Tract Infections
    www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/allergies-slides.pptx
    September 01, 2022 - testing or evidence of hemolysis (jaundice, dark urine) or thrombocytopenia (petechiae) Most commonly occur … Serum sickness Vasculitis Palpable purpura Joint pain Urticaria Lymphadenopathy Fevers Most commonly occur … Ambulatory Care Allergy History: Timing3,12 How long after starting the antibiotic did the reaction occur … Type 1 allergies occur after the first or second dose Other types usually occur days later How long … ago did the reaction occur?

68. Practice Self-Assessment Tool for Opioid Use in Older Adults (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/opioids/compendium/opioids-compendium-self-assessment.pdf
    December 01, 2023 - …occur infrequently. …occur regularly but rarely impact care planning. … …occur regularly and result in changes to care plans and chronic pain management. … …occur infrequently. …occur regularly but rarely impact care planning. … …occur regularly and result in changes to care plans and chronic pain management. … …occur infrequently. …occur regularly but do not impact care planning.

69. Action Planning Worksheets | Agency for Healthcare Research and Quality
    pcmh.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?  

70. Action Planning Worksheets | Agency for Healthcare Research and Quality
    pbrn.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?  

71. Preventable harm occurring to critically ill children. | PSNet
    psnet.ahrq.gov/issue/preventable-harm-occurring-critically-ill-children
    September 28, 2010 - Study Preventable harm occurring to critically ill children. Citation Text: Larsen G, Donaldson AE, Parker HB, et al. Preventable harm occurring to critically ill children. Pediatr Crit Care Med. 2007;8(4):331-336. Copy Citation Format: Google Scholar PubMed BibTeX EndNot…

72. Failure Mode and Effects Analysis | Digital Healthcare Research
    digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/fmea-analysis
    January 01, 2023 - mode and effects analysis (FMEA) is a method that attempts to identify all possible failures that can occur … For each function, IDENTIFY ALL THE WAYS FAILURE COULD OCCUR - i.e. the potential failure modes. … This is an estimate of the likelihood the failure will occur, and is rated on a scale from 1 to 10, with

73. Prevalence and Economic Burden of Medication Errors in the NHS England. | PSNet
    psnet.ahrq.gov/issue/prevalence-and-economic-burden-medication-errors-nhs-england
    September 11, 2018 - Prior research has shown that medication errors occur frequently and are associated with a longer hospital … The authors estimate that 237 million medication errors occur annually and that 66 million of these errors … The majority of potentially harmful errors likely occur in the outpatient setting where most medications

74. Playbook for Preventing CLABSI and CAUTI in the ICU Setting | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/clabsi-cauti-icu/implement/playbook.html
    February 01, 2025 - CUSP can be implemented through CLABSI and CAUTI prevention practices, policies, and procedures that occur

75. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/47919/psn-pdf
    April 03, 2019 - They encourage continued use of the aviation metaphor to illustrate why medical errors occur and how … when done correctly, can help health care systems identify safety hazards, regain trust after they occur

76. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/836808/psn-pdf
    March 30, 2022 - medication-safety-emergency-department-study-serious-medication-errors- reported-101-hospitals Medication errors can occur … Errors were more likely to occur on weekends and between 12:00 pm and midnight; patients were more likely

77. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/72820/psn-pdf
    March 10, 2021 - persist with long-term use of CPOE systems, but future research should explore the types of errors that occur … , when they occur, and the system factors contributing to the errors.

78. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/47291/psn-pdf
    October 31, 2018 - Little is known about the epidemiology of hospital suicides other than that they are rare and occur … Nationally, between 49 and 65 hospital suicides occur each year.

79. Failure Mode and Effect Analysis (FMEA) | PSNet
    psnet.ahrq.gov/taxonomy/term/3477
    FMEA begins with a complete process mapping that identifies all the steps that must occur for a given … process to occur (e.g., programming an infusion pump or preparing an intravenous medication in the pharmacy

80. On-Time Pressure Ulcer Healing: Facilitator Training Slide Presentation | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/facslides.html
    December 01, 2017 - Nursing homes investigate adverse events after they occur. … Is it possible to intervene before adverse events occur? … Communication: Reviews existing team meetings/huddles that occur at the facility. … 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?