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www.ahrq.gov/research/shuttered/toolkitchecklist/surgetkit3.html
July 01, 2018 - Ramp-Up
Description: Once the catastrophic event occurs, facility opening efforts will be underway … Timeframe: As soon as the catastrophic event occurs, through implementation of planned arrangements … Review/Replanning
Description: In the unfortunate event that a terrorist incident or disaster occurs … Timeframe: As soon as the catastrophic event occurs, planned arrangements for the surge facility should
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4/module4-event-reporting-investigation-analysis.pptx
September 10, 2015 - When a patient harm event occurs, rapid and timely reporting and comprehensive documentation of the details … support or inhibit disclosing information to staff, patients, and families when a patient harm event occurs … Generally speaking, about 2-4 weeks after an event occurs, a Root Cause Analysis team meets to determine … CANDOR Process for
Event Investigation and Analysis
Module 4
14
Occurs at:
30 days
60 days
90 days … Occurs within 30-45 business days after the event
Occurs within 72 hours after the event
The CANDOR
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www.ahrq.gov/es/patient-safety/settings/hospital/resource/nicu/packet/apb.html
December 01, 2013 - Diagnoses and Conditions
Anemia of Prematurity
Characteristics
Occurs during the normal developmental … Anemia is more profound and occurs earlier in premature infants due to:
Blood loss from sampling. … Can persist for many weeks in very preterm infants, although resolution typically occurs by 37-43 weeks … Yearly renal ultrasounds until resolution occurs. … Followup
A high rate of spontaneous closure occurs during the first 2 years of life.
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www.ahrq.gov/patient-safety/settings/hospital/resource/nicu/packet/apb.html
December 01, 2013 - Diagnoses and Conditions
Anemia of Prematurity
Characteristics
Occurs during the normal developmental … Anemia is more profound and occurs earlier in premature infants due to:
Blood loss from sampling. … Can persist for many weeks in very preterm infants, although resolution typically occurs by 37-43 weeks … Yearly renal ultrasounds until resolution occurs. … Followup
A high rate of spontaneous closure occurs during the first 2 years of life.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/152-cusp-tip-sheet-engaging-physicians.docx
October 01, 2024 - .
· Involve the unit physicians in the Learning From Defects process when an infection occurs. … Make it personal for them.
· If an unprofessional interaction occurs, identify a peer (e.g., attending
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/pf-engagement-facilitator-guide.docx
May 01, 2017 - Slide 17
SAY:
Each hospital has policies and procedures for actions to take after an adverse event occurs … Slide 18
Communication is an ongoing process that occurs from initial reporting of the incident through … Slide 19
SAY:
Patients and family members experience a number of emotions when an adverse event occurs … Slide 20
SAY:
When an incident occurs, the hospital will investigate and analyze it (e.g., a root … through employee assistance programs and medically induced trauma support services after an incident occurs
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www.ahrq.gov/teamstepps-program/curriculum/situation/tools/monitoring.html
June 01, 2023 - allows individuals and teams to take steps to correct the issue before harm or injury to the patient occurs
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www.ahrq.gov/nhguide/about/index.html
November 01, 2024 - Antibiotic resistance occurs when bacteria adapt so that the drugs used to treat infections are less … When this occurs, it is harder to treat infections, and residents may develop complications.
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www.ahrq.gov/hai/cusp/modules/patient-family-engagement/notes.html
September 01, 2013 - What if an Adverse Event Occurs on the Unit?
Slide 21. Engagement Strategies
Slide 22. … What if an Adverse Event Occurs on the Unit? … Hospitals must also have strategies in place to engage patients and families if an adverse event occurs … Advise the patient and family that communication will be ongoing as follow-up investigation occurs. … Next Steps in Responding to an Adverse Event 5
Say:
When an incident occurs, the hospital will
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www.ahrq.gov/prevention/guidelines/tobacco/clinicians/presentations/2008update-full/slide209.html
October 01, 2014 - The woman and her fetus will benefit even when quitting occurs late in pregnancy.
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www.ahrq.gov/hai/tools/surgery/modules/sustainability/learn-from-defects-slides.html
December 01, 2017 - X-axis is for the frequency of the factor (occurs rarely on left growing to occurs often on the right … An "X" marks the second quadrant labeled Major Contributor and Occurs Often.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-pda.pdf
June 02, 2025 - Followup
■ A high rate of spontaneous closure occurs during the first 2 years of life.
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www.ahrq.gov/patient-safety/resources/simulation-issue-brief3.html
July 01, 2024 - At the point of understanding how patient harm occurs, or how successful patient care occurs, simulations
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/144-cusp-tip-sheet-engaging-surgeons.docx
April 01, 2025 - .
· Involve surgeons in the Learning From Defects process when an infection occurs. … Make it personal for them.
· If an unprofessional interaction occurs, identify a peer (e.g., attending
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions6.html
June 01, 2023 - with high potential for diagnostic error, regardless of the care contexts between which the transition occurs
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www.ahrq.gov/teamstepps-program/curriculum/implement/activity/plan.html
February 01, 2024 - Flowchart or map the process during which the targeted problem or opportunity for improvement occurs. … Identify the process during which the problem, challenge, or opportunity occurs by stating what the process … is, who is involved, and when and where it occurs. … Look for problems or opportunities that meet the following criteria:
The associated process occurs … Ways to measure whether improvement occurs are available.
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www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/adverse-drug-events.pdf
June 02, 2025 - Adverse Drug Events occurring in U.S. Hospitals
0 10 20 30 40 50 60 70 80
Adverse Drug Events
Occurring in U.S. Hospitals
Adverse drug events (ADEs) are the most common nonsurgical adverse events that occur in hospitals.
New data from all payers in 32 States in HCUP show characteristics of the four most frequent …
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module4/facilitator-notes.docx
March 01, 2017 - A Brief usually occurs at the beginning of the shift and is designed to help all team members develop … SLIDE 11
SAY:
A Debrief is an informal but structured discussion of an event after it occurs. … Each facility has policies and procedures to follow after an adverse event occurs, and most involve working … And remember, communication is an ongoing process that occurs from initial reporting of the incident … When an incident occurs, the facility should investigate and analyze it (for example, conduct a root
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/vtguide/umich-slides.ppt
May 20, 2012 - prophylaxis included as peer review (OPPE) indicator for many services
Review of EVERY VTE event that occurs
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-nephro.pdf
June 02, 2025 - – Yearly renal ultrasounds until resolution occurs.