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61. How to Talk About Patient Safety. | PSNet
    psnet.ahrq.gov/issue/how-talk-about-patient-safety
    June 24, 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

62. Assessment of Pediatric Look-Alike, Sound-Alike (LASA) Substitution Errors - 2011 | Digital Healthcare Research
    digital.ahrq.gov/ahrq-funded-projects/assessment-pediatric-look-alike-sound-alike-lasa-substitution-errors/annual-summary/2011
    January 01, 2011 - AHRQ Funding Amount $100,000 Summary: Look-alike, sound-alike (LASA) medication errors occur … The respondents are asked: "Please score the severity of the potential harm that might occur from not … identifying drugs that the participants felt were of high potential harm to a patient should a substitution occur

63. AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/slides.html
    December 01, 2014 - 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?

64. PowerPoint Presentation
    www.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?

65. PowerPoint Presentation
    www.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?

66. FAQs (Staff): Safety and Side Effects: CHG and Mupirocin (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/faqs/faq-safety-chg-mupirocin.docx
    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.

67. Critical incidents involving the medical emergency team: a 5-year retrospective assessment for healthcare improvement. | PSNet
    psnet.ahrq.gov/issue/critical-incidents-involving-medical-emergency-team-5-year-retrospective-assessment
    November 11, 2020 - effectiveness of medical emergency teams (MET) has been widely researched , critical incidents that occur … Related Resources From the Same Author(s) Do falls and other safety issues occur

68. Equipment and Supplies | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/shuttered/toolkitchecklist/surgetkit3.html
    July 01, 2018 - Timeframe: The operations activities listed below will occur between opening day and until the facility … The steps listed below must occur for this process to be successful. … will be transported within the first few days, but continued patient transport to the facility might occur … Also, termination of on-going contracts or arrangements must occur. … determined that the surge facility is no longer needed, all patient transport out of the facility should occur

69. Scisafetynotes (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/understand/scisafetynotes.docx
    June 02, 2025 - Slide 4 SAY: Errors occur within the health care setting because people are fallible. … Providers, executives, and managers need to understand why errors occur. … Errors occur because medicine is still treated as an art, not a science. … In analyzing how errors occur, frontline providers must recognize the scientific nature of medicine. … Errors also occur because systems frequently do not catch mistakes before they reach the patient.

70. Addressing Questions Asked by Staff: Safety and Side Effects of Chlorhexidine and Mupirocin (pdf file)
    www.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.

71. The potential for improved teamwork to reduce medical errors in the emergency department. | PSNet
    psnet.ahrq.gov/issue/potential-improved-teamwork-reduce-medical-errors-emergency-department
    July 07, 2021 - to introduce emergency department communities to teamwork systems, teamwork failures that commonly occur … includes retrospective analysis of more than 50 incidents suggesting that nearly nine teamwork failures occur

72. 047-Ss-Faqs-Staff-Safety-Side-Effects (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/047-ss-faqs-staff-safety-side-effects.docx
    April 01, 2025 - Local CHG side effects are estimated to occur in 1–3 percent of patients. … For example, this may occur if CHG enters the ear canal of patient with a perforated ear drum.

73. Understand the Science of Safety for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/understand-sci-fac-guide.html
    July 01, 2023 - Say: Errors occur within the health care setting because health care professionals are human, and humans … Providers, executives, and managers need to understand why errors occur. … Errors occur because medicine is still treated as an art, not a science. … In analyzing how errors occur, frontline providers must recognize the scientific nature of medicine. … Errors also occur because systems frequently do not catch mistakes before they reach the patient.

74. Final Progress Report: Crossing an Invisible Quality Chasm: From NICU to Ambulatory Care (pdf file)
    www.ahrq.gov/sites/default/files/2024-12/moyer-report.pdf
    January 01, 2024 - Each failure mode was then scored on two parameters: the probability that it could occur (frequency … score) and the severity of the potential outcome if it did occur (severity score). … N/A Greater than 1x/week 5 N/A Greater than 1x/month but less than 1x/week 4 Frequent: Likely to occur … several times in 1 year) Greater than 1x/year but less than 1x/month 3 Occasional: Probably will occur … (may happen several times in 1 to 2 years) Less than 2x/year 2 Uncommon: Possible to occur (may

75. Introduction | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/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

76. Medication safety in the emergency department: a study of serious medication errors reported by 101 hospitals from 2011 to 2020. | PSNet
    psnet.ahrq.gov/issue/medication-safety-emergency-department-study-serious-medication-errors-reported-101-hospitals
    March 24, 2021 - Medication errors can occur in all clinical settings , but can have especially devastating results … Errors were more likely to occur on weekends and between 12:00 pm and midnight; patients were more likely

77. Learning From Defects Through Sensemaking: Slide Presentation | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-slides.html
    December 01, 2017 - List contributing factors that make defects in care more likely to occur. … The “5 Why’s” technique can help: Why 1: Why did this contributing factor occur? … Why 2: Why did the answer to “Why 1” occur? Why 3: Why did the answer to “Why 2” occur? … Why 4: Why did the answer to “Why 3” occur? Why 5: Why did the answer to “Why 4” occur? … Does it occur rarely or have a high likelihood of reoccurring?

78. Incidence and method of suicide in hospitals in the United States. | PSNet
    psnet.ahrq.gov/issue/incidence-and-method-suicide-hospitals-united-states
    October 04, 2023 - Little is known about the epidemiology of hospital suicides other than that they are rare and occur mostly … Nationally, between 49 and 65 hospital suicides occur each year.

79. Failure Mode and Effect Analysis (FMEA) | PSNet
    psnet.ahrq.gov/glossary/failure-mode-and-effect-analysis-fmea
    September 13, 2021 - 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. Comprehensive Diabetes Care: Blood Pressure Control (<140/90 mm Hg) (pdf file)
    integrationacademy.ahrq.gov/sites/default/files/2020-07/Comprehensive_Diabetes_Care_Blood_Pressure.pdf
    January 01, 2020 - Diagnosis may occur at any time in the member’s history, but must have occurred by the end of the measurement … Diagnosis may occur during the measurement year or the year prior to the measurement year, but must