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61. Chapter 9. Potential Future Uses of the Data Infrastructure | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/practiceimprovement/delivery-initiative/ihs/chapter9.html
    December 01, 2017 - following the visit may be used to assess if laboratory testing, medication changes, and ECM service use occurred … If such service use occurred following the visit, the office visit may be classified as a clinical opportunity

62. TeamSTEPPS 2.0: Summary Skills Practice Exercise Sheet (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module7/exsummary.pdf
    March 20, 2014 - Identify the instances where a breakdown in teamwork has occurred as it relates to the specific teamwork

63. PowerPoint Presentation: Learn From Defects for Sustainability
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_learn_from_defects.pptx
    December 01, 2017 - ASK: What if the same situation occurred on a different shift? … SAY: When a defect has already occurred, ask your frontline staff. … ASK: How do all these pieces lead to this error or the event that occurred? … If you can, simulate the defect, particularly for a defect that has occurred. … What actions occurred? What were care team members thinking and feeling?

64. Does Medical Error Disclosure Violate the Medical Malpractice Insurance Cooperation Clause? (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Banja.pdf
    January 01, 2004 - medical error, which is morally required of physicians when they know that a harm-causing error has occurred … ethically required to inform the patient of all the facts necessary to ensure understanding of what has occurred … Jones, an error occurred in your care that was responsible for the harm you experienced, and we apologize … An example of this occurred in Royston Moore v. … health professionals to desist from admitting liability when they know that harm-causing error has occurred

65. Mod01-Grand-Rounds-Slides (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/grandrounds/mod01-grand-rounds-slides.pdf
    April 01, 2016 - An explicit statement that an error occurred. 2. … The Investigation: to determine how the event occurred, and how to mitigate that event or even prevent … This is a cornerstone of the CANDOR process of investigating the root cause of how an error occurred … disclosure is a process, and the first step is to: ■ Let the patient and family know an adverse event occurred … result of the investigation and analysis of Michelle’s case, the following patient safety changes occurred

66. On-Time Falls Prevention: Electronic Reports (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallpxsamplereports.pdf
    November 06, 2017 - within the facility’s electronic medical record, such as nurse assessments, and represent changes that occurred … facility’s electronic medical record as determined by the facility and may represent changes that occurred … Summary of Fall Risk Factors Report is a count of risk factors associated with the falls that have occurred … For each month, it displays the number of falls that occurred and the risk factors associated with … , • Shift during which the fall occurred, • Time at which the fall occurred, • The location of the

67. Transformation to the Patient-Centered Medical Home in CareOregon Clinics | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/ncepcr/research-transform-primary-care/transform/profile/meenan.html
    October 01, 2015 - Qualitative interviews with organizational leaders revealed that implementation occurred in two distinct … At 1 year post-implementation, 5.39 fewer inpatient admissions per month occurred in the PCR clinics

68. Module 1: Communication and Optimal Resolution (CANDOR) Toolkit Module 1: An Overview of the CANDOR Process
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/module1-overview.pptx
    May 19, 2016 - understand what a CANDOR event is and what to do when they recognize that a CANDOR event is occurring or has occurred … Activity: List de-identified events that have occurred in your organization. … Once activated, the CANDOR Response Team will work with the caregivers where the event occurred to ensure

69. PowerPoint Presentation
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/grand-rounds-presentation-slides.pptx
    January 01, 2014 - to remember what patients want in our communication with them: An explicit statement that an error occurred … The Investigation: to determine how the event occurred, and how to mitigate that event or even prevent … This is a cornerstone of the CANDOR process of investigating the root cause of how an error occurred, … “Don’t tell me you were sorry that the problem occurred. … disclosure is a process, and the first step is to: Let the patient and family know an adverse event occurred

70. The Association Between Pharmacist Support and Voluntary Reporting of Medication Errors: An Analysis of MEDMARX® Data (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Jones_91.pdf
    July 17, 2008 - but it did not reach the patient 14.9 23.9 40.9 C Error occurred that reached the patient but did … not cause harm 53.6 49.8 43.4 D Error occurred that reached the patient and required monitoring to … that might have contributed to or resulted in permanent patient harm 0.0 0.0 0.0 H Error occurred … that required intervention necessary to sustain life 0.0 0.0 0.0 I Error occurred that … We do believe, however, that it is unlikely that misclassifications of errors occurred to an extent

71. Dear [NURSES NAMES]-- (doc file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/clabsitools/clabsitoolsap9.doc
    December 11, 2012 - Because the event occurred more than 48 hours from the time of line insertion, it is clear that this

72. Dear [NURSES NAMES]-- (doc file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/clabsitools/clabsitoolsap8.doc
    December 11, 2012 - Because the event occurred more than 48 hours from the time of line insertion, it is clear that this

73. Physician-Reported Adverse Events and Medical Errors in Obstetrics and Gynecology (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-November_45.pdf
    January 01, 2007 - House officers were encouraged to fill out cards immediately after reportable events occurred and to … following definitions were used to code the type of event: • Adverse events were injuries that occurred … • Potential adverse events were errors where injuries could have occurred but did not, either due … For example, quality problems (other than AEs and potential AEs) occurred when appropriate instruments … alternatively, might have generated a greater number of reports, since more potential events could have occurred

74. TeamSTEPPS Specialty Scenarios: Dental (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/scenarios/dental.pdf
    March 19, 2014 - In this scenario, either of two actions should have occurred. … Had a brief or check-back occurred, they would have shared their individual situation awareness with

75. PowerPoint Presentation: Learn From Defects Through Sensemaking
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects.pptx
    December 01, 2017 - So, first look at the system and analyze why the mistake occurred. … What actions occurred? What were the team members thinking and feeling? … SAY: These are the types of questions to ask to understand how a defect occurred. … Try to find out exactly how things occurred in real time. 13 What Happened? … What actions occurred? What were care team members thinking and feeling?

76. Best Practices in the Diagnosis and Treatment of Community-Associated Lower Respiratory Tract Conditions (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/best-practices/respiratory-facilitator-guide.pdf
    November 01, 2019 - Treat as community-acquired pneumonia if the event occurred within 72 hours of admission to a healthcare … healthcare-associated pneumonia with agents like cefepime or piperacillin/tazobactam if the event occurred … antibiotics without improvement within 48 hours: Treat as community- acquired pneumonia if the event occurred … Treat as healthcare-associated pneumonia if the event occurred 72 hours or more after admission to a

77. Best Practices in the Management of Patients With Antibiotic Allergies – Facilitator Guide (doc file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/allergies-guide.docx
    September 01, 2022 - specific symptoms that led to the diagnosis of the penicillin allergy, particularly when the reaction occurred … SAY: If the patient reports an allergy, ask how long after they started the antibiotic the reaction occurred … Also, ask how long ago the reaction occurred. … Ask her to describe what the rash looked like, how often after the first dose of antibiotics it occurred

78. Module 5: How To Measure Fall Rates and Fall Prevention Practices (doc file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module5/module5_fall-prevention.docx
    June 30, 2017 - When the fall occurred. What the degree of injury was, if any. … First, count the number of falls that occurred during the month from your incident reporting system. … Try to understand why the fall occurred and how such an incident might be prevented in the future. … individual data points are plotted and then connected (as shown by the blue line) to show that they occurred … However, it also shows a breakdown of the fall rate by the different types of falls that occurred—anticipated

79. Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Health Care November Meeting Summary (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/topics/fed-IWG-dxsafety-Nov19mtg.pdf
    November 15, 2019 - Workgroup Summary: The latest workgroup meeting occurred virtually on November 15, 2019, from 10 a.m

80. Chapter 2. Fall Response | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man2.html
    December 01, 2017 - Unless there is evidence suggesting otherwise, the most logical conclusion is that a fall has occurred … distance to the next lower surface (in this case, the floor) is not a factor in determining whether a fall occurred … , an immediate intervention should be put in place by the nurse during the same shift that the fall occurred