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1. Surge in Drug Shortages Occurred in Wake of Pandemic, Study Finds | Agency for Healthcare Research and Quality
   monahrq.ahrq.gov/news/newsletters/e-newsletter/908.html
   April 01, 2024 - Home News Newsletter AHRQ News Now Surge in Drug Shortages Occurred … Newsletter AHRQ News Now Events Surge in Drug Shortages Occurred … Today's Headlines: Surge in Drug Shortages Occurred in Wake of Pandemic, Study Finds April 23 Webinar … Surge in Drug Shortages Occurred in Wake of Pandemic, Study Finds A recent AHRQ-funded study on pharmaceutical … 2024 Page originally created April 2024 Internet Citation: Surge in Drug Shortages Occurred

2. National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data From National Efforts To Make Health Care Safer | Agency for Healthcare Research and Quality
   monahrq.ahrq.gov/hai/pfp/2015-interim.html
   December 01, 2016 - over the 5 years (2011, 2012, 2013, 2014, and 2015) relative to the number of HACs that would have occurred … precise causes of the decline in patient harm are not fully understood, the increase in safety has occurred … in 2015 than would have occurred if the rate of HACs had remained steady at the 2010 level ( Exhibit … Cumulatively, approximately 3.1 million fewer incidents of harm occurred in 2011, 2012, 2013, 2014, and … on October 1, 2015, and also due in part to delays in contracting for MPSMS data analysis that occurred

3. Saving Lives and Saving Money: Hospital-Acquired Conditions Update | Agency for Healthcare Research and Quality
   monahrq.ahrq.gov/hai/pfp/2014-final.html
   January 01, 2018 - precise causes of the decline in patient harm are not fully understood, the increase in safety has occurred … in 2014 than would have occurred if the rate of HACs had remained steady at the 2010 level ( Exhibit … Cumulatively, approximately 2.1 million fewer incidents of harm occurred in 2011, 2012, 2013, and 2014 … Most of the deaths averted occurred as a result of reductions in the rates of pressure ulcers and adverse … An estimated 2.1 million fewer HACs were experienced by patients from 2010 to 2014 than would have occurred

4. Morningbriefing (doc file)
   monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/morningbriefing.doc
   August 07, 2012 - : This tool provides a structured approach to help physicians and nurses identify the problems that occurred … If an adverse event occurred, you should also use the Learn From Defects Form. II.

5. NPSD Data Spotlight - Patient Safety and COVID-19: A Qualitative Analysis of Concerns During the Public Health Emergency (pdf file)
   monahrq.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-ptsafety-and-covid-19.pdf
   November 01, 2021 - There is no evidence in these reports that any other type of patient safety concern occurred. … In several instances, the exposure occurred because staff were not following PPE protocols, such as … In other cases, the exposure occurred with an asymptomatic individual, and was later identified when … Additional near misses occurred when the wrong blood product (e.g., fresh frozen plasma versus COVID … PSOs generally provided data elements for the location in the facility where the event occurred and

6. Final Data From National Efforts To Make Care Safer, 2010-2014 (pdf file)
   monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/2014FinalHACreport4Web-13Dec2016.pdf
   December 01, 2016 - patients over the 4 years (2011, 2012, 2013, and 2014) relative to the number of HACs that would have occurred … precise causes of the decline in patient harm are not fully understood, the increase in safety has occurred … the reduction in the rate of HACs, we estimate that approximately 798,000 fewer incidents of harm occurred … in 2014 than would have occurred if the rate of HACs had remained steady at the 2010 level (Exhibit … Cumulatively, approximately 2.1 million fewer incidents of harm occurred in 2011, 2012, 2013, and 2014

7. Module 4: Event Reporting, Event Investigation and Analysis | Agency for Healthcare Research and Quality
   monahrq.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes4.html
   August 01, 2022 - information, other than event reports, that might provide information indicating that a CANDOR event has occurred … create a cohesive environment for informing the organization as to whether a CANDOR event may have occurred … implement the best practice of creating a hotline for staff to call when they feel a CANDOR event has occurred … Risk Management can also provide ongoing support to managers on the unit(s) where the event occurred. … Also, the location where the event occurred is generally no longer intact, so information that could

8. Module 6: Care for the Caregiver | Agency for Healthcare Research and Quality
   monahrq.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes6.html
   August 01, 2022 - , but they feared that an error may have occurred. … This stage is characterized by either the second-victim realizing that an event has occurred, or the … organization recognizing that an event has occurred. … The second-victim might not be able provide care in the room where the event occurred and might appear … The event might produce feelings of internal inadequacy, either because the event occurred or because

9. Mod5-Disclosure-Checklist (pdf file)
   monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/mod5-disclosure-checklist.pdf
   April 01, 2016 - after the CANDOR event is identified, advise the patient and/or family that an adverse event may have occurred … ■ Explain what is known about why the adverse event occurred; do not speculate.

10. USER GUIDE: Hand Hygiene Observational Audit Data Tracking Tool for Use in Skilled Nursing Facilities (pdf file)
    monahrq.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/hand-hygiene-audit-tool-userguide.pdf
    April 01, 2021 - location within your facility where the observational audit of the employee’s hand hygiene activity occurred … Next enter the date the audit occurred using the month/day/four-digit year format in Column E. … Select the time block that aligns with the time the audit occurred for the employee observed.

11. Module 5: Response and Disclosure | Agency for Healthcare Research and Quality
    monahrq.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/notes.html
    August 01, 2022 - The patient and/or family have a reasonable expectation to be informed when a harm event has occurred … of this initial conversation is to advise the patient and/or family that an adverse event may have occurred … During disclosure, patients and families generally want a clear, explicit statement that an event has occurred … what happened in a way that is easy to understand, explain what is known about why the adverse event occurred … If the event was preventable and occurred due to error, the communicator should: Consider using

12. Grand Rounds Presentation | Agency for Healthcare Research and Quality
    monahrq.ahrq.gov/patient-safety/settings/hospital/candor/grand-rounds.html
    August 01, 2022 - 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, … disclosure is a process , and the first step is to: Let the patient and family know an adverse event occurred … a result of the investigation and analysis of Michelle’s case, the following patient safety changes occurred

13. Module 1: An Overview of the CANDOR Process | Agency for Healthcare Research and Quality
    monahrq.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes1.html
    August 01, 2022 - understand what a CANDOR event is and what to do when they recognize that a CANDOR event is occurring or has occurred … Do: 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

14. AHRQ's Safety Program for Nursing Homes: On-Time Falls Prevention Training (pdf file)
    monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallpxreports-ig.pdf
    November 09, 2017 - The new contributing risk factor elements represent changes that occurred in a resident’s clinical … It displays the number of falls that occurred and the risk factors associated with the falls. … For each of the months (1 or 3) included in the report, any fall that occurred before the report date … For each of the months (1 or 3) included in the report, any fall that occurred before the report date … ,  Shift during which the fall occurred,  Time at which the fall occurred,  The location of

15. Disclosure Checklist | Agency for Healthcare Research and Quality
    monahrq.ahrq.gov/patient-safety/settings/hospital/candor/modules/checklist5.html
    August 01, 2022 - after the CANDOR event is identified, advise the patient and/or family that an adverse event may have occurred … Explain what is known about why the adverse event occurred; do not speculate.  

16. Mod01-Grand-Rounds-Slides (pdf file)
    monahrq.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

17. PowerPoint Presentation
    monahrq.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

18. Module 5: How To Measure Fall Rates and Fall Prevention Practices (doc file)
    monahrq.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

19. Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Health Care November Meeting Summary (pdf file)
    monahrq.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

20. AHRQ Impact Case Studies Criteria | Agency for Healthcare Research and Quality
    monahrq.ahrq.gov/news/newsroom/case-studies/criteria.html
    December 01, 2019 - Impact or results must have already occurred.