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41. PowerPoint Presentation
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/grand-rounds-presentation-slides.pptx
    January 01, 2014 - Response, Mitigation, Prevention Module 1 19 Once the CANDOR system is activated, two processes are occurring … Investigation: to determine how the event occurred, and how to mitigate that event or even prevent it from occurring … organization as a whole, with feedback on the investigation and its plans to prevent the adverse harm from occurring … allowing for clarification and improvement of the CANDOR processes and preventing similar harm events from occurring … along with information as to what action the organization is taking to prevent a similar event from occurring

42. Introduction and Evidence for Early Mobility: A Protocol To Get Patients Out of Bed Faster: Facilitator Guide | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/mvp/modules/technical/intro-early-mobility-fac-guide.html
    February 01, 2017 - following ICU discharge. 45 percent of observed patients experienced an early death, defined as death occurring … In addition, when a functional decline was already occurring prior to admission, the patient had a higher

43. Part 3: National Quality Strategy Priority—Patient Safety | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/findings/nhqrdr/chartbooks/blackhealth/part3-nqs2.html
    June 01, 2018 - much more commonly treated at visits to outpatient settings, with more than 12 million such visits occurring … Events treated in ambulatory settings may be less severe than those occurring in inpatient settings.

44. Introduction to Diagnostic Errors | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-cognitive-load1.html
    May 01, 2024 - CLT as it applies to diagnostic accuracy is a relatively new area of study, with most of the research occurring

45. 4 Tk1 T3-Not All Infections Need Antibiotics- Final (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/nhguide/4_TK1_T3-Not_all_Infections_need_antibiotics-_final.pdf
    May 01, 2014 - Infections caused by multidrug resistant organisms are occurring more frequently in residents.

46. Tampa Hospital Uses AHRQ Tools to Reduce Emergency Department CAUTI Rates by 75 Percent | Agency for Healthcare Research and Quality
    www.ahrq.gov/news/newsroom/case-studies/201808.html
    December 01, 2018 - Insertion-related CAUTI was considered any CAUTI occurring within 7 days of insertion of an indwelling

47. Tool: OR Briefing and Debriefing Audit Tool (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/tools/applying-cusp/or_briefing_audit.docx
    December 01, 2017 - physically present in the room Paused other tasks: not engaged in other tasks while the briefing was occurring

48. Operating Room Briefing and Debriefing Audit Tool | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/surgery/tools/applying-cusp/or-briefing-audit.html
    December 01, 2017 - Paused other tasks : not engaged in other tasks while the briefing was occurring.

49. Urinary Tract Infections (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/uti-one-pager.pdf
    September 01, 2022 - infections (UTIs)  Suspected complicated UTIs − UTIs in adolescent or adult males or UTIs in a female occurring

50. Grantees Focusing on Hispanic and Latino Populations | Agency for Healthcare Research and Quality
    www.ahrq.gov/priority-populations/observances/hispanic-heritage/index.html
    October 01, 2021 - psychiatric perspective when they are fully interviewed in their own language, with the translation occurring

51. Ventilator-Associated Pneumonia (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/best-practices/VAP-one-page.docx
    November 01, 2019 - Ventilator-Associated Pneumonia Ventilator-Associated Pneumonia Diagnosis · Defined as pneumonia occurring

52. Prioritization Worksheet (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/c1_pdi_prioritizationworksheetinstructions.pdf
    June 02, 2025 - In column E, “Volume of Cases at Risk,” indicate the annual volume of each PDI event occurring within … This number is the total raw number of events occurring within your organization for your chosen time

53. | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/publications/search.html?page=17
    October 01, 2011 - research and implementation projects, offers these 10 evidence-based tips to prevent adverse events from occurring

54. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/intro-early-mobility-facguide.docx
    January 01, 2017 - following ICU discharge. 45 percent of observed patients experienced an early death, defined as death occurring … In addition, when a functional decline was already occurring prior to admission, the patient had a higher

55. A Practical Guide for Estimating the Costs of Primary Care Transformation | Agency for Healthcare Research and Quality
    www.ahrq.gov/ncepcr/research-transform-primary-care/transform/cost/guide.html
    October 01, 2015 - effort; factors not related to the PCMH transformation effort, such as changes in patient mix and co-occurring … transformation can help to distinguish changes caused by transformation efforts versus other trends or co-occurring … Costs may be affected by co-occurring quality improvement or other initiatives whose activities overlap

56. A Practical Guide for Estimating the Costs of Primary Care Transformation | Agency for Healthcare Research and Quality
    www.ahrq.gov/ncepcr/reports/cost-guide/practical-guide.html
    February 01, 2017 - effort; factors not related to the PCMH transformation effort, such as changes in patient mix and co-occurring … transformation can help to distinguish changes caused by transformation efforts versus other trends or co-occurring … Costs may be affected by co-occurring quality improvement or other initiatives whose activities overlap

57. Prioritization Worksheet (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheetinstructions.pdf
    June 02, 2025 - column E, “Volume of Cases at Risk,” indicate the annual volume of each PSI, IQI, and/or PDI event occurring … This number is the total raw number of events occurring within your organization for your chosen time

58. Developing Innovative Simulation-Based Training to Improve Patient Safety in Radiation Oncology | Agency for Healthcare Research and Quality
    www.ahrq.gov/funding/grantee-profiles/grtprofile-mazur.html
    March 01, 2023 - While radiation therapy has relatively low error and injury rates, studies show that most errors occurring

59. Session 2 | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mod3sess2.html
    October 01, 2014 - Staff must be able to document how many falls are occurring in a given time period and why those falls … are occurring.

60. Final Progress Report: Proactive Risk Reduction in Medication Prescribing in the Ambulatory Setting (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/field2-report.pdf
    January 01, 2024 - risk assessment directed at selecting interventions to lessen the rate of serious adverse drug events occurring … For many proximal errors, a long string of events would lead to the error occurring with no safety checks … previously found this error to be responsible for 41% of the preventable serious adverse drug events occurring … – the most common cause of serious, preventable adverse drug events and by far the most frequently occurring