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www.ahrq.gov/sites/default/files/2024-11/wakefield2-report.pdf
January 01, 2024 - Final Progress Report: Verbal Order Policies, Occurrence, and Perceptions
Verbal Order Policies, Occurrence … to minimize potential errors and adverse events; 2) develop estimates of
inpatient VO frequency and occurrence … Obtain estimates of inpatient verbal and telephone order frequency and
occurrence based on surveying … Conclusions – Future Work
Despite their common occurrence, little systematic study of verbal orders … mailto:brandtju@health.missouri.edu
Verbal Order Policies, Occurrence, and Perceptions
Structured
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psnet.ahrq.gov/issue/patient-characteristics-and-occurrence-never-events
February 15, 2011 - Study
Patient characteristics and the occurrence of never events. … Patient characteristics and the occurrence of never events. … Patient characteristics and the occurrence of never events.
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psnet.ahrq.gov/issue/tubing-misconnections-persistent-and-potentially-deadly-occurrence
March 14, 2018 - Newspaper/Magazine Article
Tubing misconnections—a persistent and potentially deadly occurrence … Tubing misconnections--a persistent and potentially deadly occurrence. … on Accreditation of Healthcare Organizations (JCAHO) and recommends 10 strategies to prevent their occurrence … Tubing misconnections--a persistent and potentially deadly occurrence.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Arroyo.pdf
June 11, 2003 - Automated Occurrence Screen Database input screen
Figure 3. … Once an occurrence is closed, the risk manager archives the report. … The
usual occurrence can be closed out in as little as 72 hours. … Occurrence screen reporting flow diagram
Figure 2. … Automated Occurrence Screen Database input screen
Figure 3.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Rojas.pdf
March 15, 2004 - an adverse
occurrence. … Sixty-three percent of patients did
not have an adverse occurrence. … on admission
Total not
impaired
on admit
No adverse
occurrence
Adverse
occurrence
Odds … without an
adverse occurrence. … Median lengths of stay, in days (N = 1,545)
Surgical procedure No adverse
occurrence
Adverse
occurrence
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psnet.ahrq.gov/issue/nature-and-occurrence-registration-errors-emergency-department
September 28, 2016 - Study
The nature and occurrence of registration errors in the emergency department … The nature and occurrence of registration errors in the emergency department. … The nature and occurrence of registration errors in the emergency department.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Rudman.pdf
January 01, 2004 - The Impact of a Web-based Reporting System on the Collection of Medication Error Occurrence Data
195 … The Impact of a Web-based Reporting
System on the Collection of Medication
Error Occurrence Data … Web-based method of
occurrence report collection
Prior to December 2002, occurrence reports were … Going paperless with custom-built Web-
based patient occurrence reporting. … Person documented in the occurrence report as responsible for the medication
Table 3.
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psnet.ahrq.gov/issue/relationship-between-occurrence-surgical-complications-and-hospital-finances
April 21, 2015 - Study
Classic
Relationship between occurrence of surgical … Relationship between occurrence of surgical complications and hospital finances. … Relationship between occurrence of surgical complications and hospital finances.
-
www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-203-section-8-a-data-feasibility.pdf
June 02, 2025 - B
Must be within 24 hours of admission N/A
4 Appropriateness of Red Cell
Transfusions
Occurrence … of Red Cell
Transfusions
Date of Occurrence A Admission date/time
4 Appropriateness of Red Cell … Transfusions
Occurrence of a blood
transfusion (Occurrence B)
May be identified by: SNOMED-CT 116863004 … Documentation of
hemoglobin level
(Occurrence C)
Patient has documentation that he/she
received … of a PICU
discharge (Occurrence B)
Patient was discharged from PICU N/A
5 Initial Baseline Screen
-
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-199-section-8-a-ehr-data-feasibility-tool.pdf
June 02, 2025 - B
Must be within 24 hours of admission N/A
4 Appropriateness of Red Cell
Transfusions
Occurrence … of Red Cell
Transfusions
Date of Occurrence A Admission date/time
4 Appropriateness of Red Cell … Transfusions
Occurrence of a blood
transfusion (Occurrence B)
May be identified by: SNOMED-CT 116863004 … Documentation of
hemoglobin level
(Occurrence C)
Patient has documentation that he/she
received … of a PICU
discharge (Occurrence B)
Patient was discharged from PICU N/A
5 Initial Baseline Screen
-
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-200-section-8-data-feasibility-tool-1.pdf
June 02, 2025 - B
Must be within 24 hours of admission N/A
4 Appropriateness of Red Cell
Transfusions
Occurrence … of Red Cell
Transfusions
Date of Occurrence A Admission date/time
4 Appropriateness of Red Cell … Transfusions
Occurrence of a blood
transfusion (Occurrence B)
May be identified by: SNOMED-CT 116863004 … Documentation of
hemoglobin level
(Occurrence C)
Patient has documentation that he/she
received … of a PICU
discharge (Occurrence B)
Patient was discharged from PICU N/A
5 Initial Baseline Screen
-
psnet.ahrq.gov/issue/swiss-cheese-model-adverse-event-occurrence-closing-holes
September 25, 2024 - Commentary
The Swiss cheese model of adverse event occurrence—closing the holes. … The Swiss cheese model of adverse event occurrence--Closing the holes. … The Swiss cheese model of adverse event occurrence--Closing the holes.
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psnet.ahrq.gov/issue/design-retrospective-patient-record-study-occurrence-adverse-events-among-patients-dutch
December 29, 2014 - Study
Design of a retrospective patient record study on the occurrence of adverse … Design of a retrospective patient record study on the occurrence of adverse events among patients in … The researchers applied the Harvard study methodology to study the occurrence of adverse events in … Design of a retrospective patient record study on the occurrence of adverse events among patients in
-
digital.ahrq.gov/ahrq-funded-projects/detecting-med-medication-errors-rural-hospitals-using-technology/citation
January 01, 2023 - The impact of a Web-based reporting system on the collection of medication error occurrence data. … The impact of a Web-based reporting system on the collection of medication error occurrence data.
-
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-199-section-2-chart-tech-specs.pdf
January 01, 2013 - AND: Intersection of:
"Encounter, Performed: PICU Admission or Transfer (Occurrence A)" <= 24 hour(s … A) (admission datetime)"
"Encounter, Performed: PICU Admission or Transfer (Occurrence A) (discharge … OR: Union of:
"Occurrence of Diagnostic Study, Performed: an administration of a nutritional status … AND: Intersection of:
"Occurrence of Diagnostic Study, Performed: an administration of a nutritional … status
screening tool that is standardized within the institution (Occurrence C)"
"Occurrence of Diagnostic
-
psnet.ahrq.gov/node/866557/psn-pdf
August 21, 2024 - Minimization of occurrence of retained surgical items
using machine learning and deep learning techniques … Minimization of occurrence of retained surgical items
using machine learning and deep learning techniques … https://psnet.ahrq.gov/issue/minimization-occurrence-retained-surgical-items-using-machine-learning-and … https://psnet.ahrq.gov/issue/minimization-occurrence-retained-surgical-items-using-machine-learning-and-deep-learning … https://psnet.ahrq.gov/issue/minimization-occurrence-retained-surgical-items-using-machine-learning-and-deep-learning
-
psnet.ahrq.gov/node/60666/psn-pdf
July 08, 2020 - Maximum emergency department overcrowding is
correlated with occurrence of unexpected cardiac arrest … Maximum emergency department overcrowding is correlated with
occurrence of unexpected cardiac arrest … https://psnet.ahrq.gov/issue/maximum-emergency-department-overcrowding-correlated-occurrence-
unexpected-cardiac-arrest … https://psnet.ahrq.gov/issue/maximum-emergency-department-overcrowding-correlated-occurrence-unexpected-cardiac-arrest … https://psnet.ahrq.gov/issue/maximum-emergency-department-overcrowding-correlated-occurrence-unexpected-cardiac-arrest
-
psnet.ahrq.gov/node/73065/psn-pdf
March 24, 2021 - Implementing the clinical occurrence reporting and
learning system: a double-loop learning incident … Implementing the clinical occurrence reporting and learning system: a
double-loop learning incident … https://psnet.ahrq.gov/issue/implementing-clinical-occurrence-reporting-and-learning-system-double-loop … https://psnet.ahrq.gov/issue/implementing-clinical-occurrence-reporting-and-learning-system-double-loop-learning-incident … https://psnet.ahrq.gov/issue/implementing-clinical-occurrence-reporting-and-learning-system-double-loop-learning-incident
-
www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit4-14.html
November 01, 2014 - "[The county hospital district] believes that the environment and care processes contribute to the occurrence … The hospital is committed to reducing the occurrence of UTIs to a rate that is at or below the national
-
psnet.ahrq.gov/node/836997/psn-pdf
April 27, 2022 - The effect of a transitional pharmaceutical care program
on the occurrence of ADEs after discharge from … The effect of a transitional pharmaceutical care program on
the occurrence of ADEs after discharge from … https://psnet.ahrq.gov/issue/effect-transitional-pharmaceutical-care-program-occurrence-ades-after- … https://psnet.ahrq.gov/issue/effect-transitional-pharmaceutical-care-program-occurrence-ades-after-discharge-hospital … https://psnet.ahrq.gov/issue/effect-transitional-pharmaceutical-care-program-occurrence-ades-after-discharge-hospital