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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/pf-engagement-fac-guide.html
July 01, 2023 - Event
Say:
Each hospital has policies and procedures for actions to take after an adverse event occurs … Slide 19: Adverse Event Initial Communication
Say:
Communication is an ongoing process that occurs … Event
Say:
Patients and family members experience a number of emotions when an adverse event occurs … Slide 21: Next Steps in Responding to an Adverse Event
Say:
When an incident occurs, the hospital … through employee assistance programs and medically induced trauma support services after an incident occurs
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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/evidencenow/results/research/recruitment-timeline-nw.pdf
June 19, 2015 - recruitment
database
wit
hi
n
1
W
ee
k
i
Phone call
between
recruiter and
practice occurs … completing
forms if possible)
• Identify QI
champion
W
i
thi
n
2
w
ee
ks Kick-off Site visit
occurs
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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/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/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/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/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/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/funding/training-grants/r36.html
November 01, 2023 - Per the NOFO, the review meeting generally occurs 4 months after application receipt, and the anticipated … grant start date (if funded) generally occurs 4 months after the review meeting.
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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/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/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.
-
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.
-
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
-
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
-
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/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
-
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.
-
www.ahrq.gov/patient-safety/settings/hospital/candor/index.html
August 01, 2022 - A traditional approach when unexpected harm occurs often follows a "deny-and-defend" strategy, providing