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  1. www.ahrq.gov/cpi/about/mission/strategic-plan/tribal-consultation-policy.html
    August 01, 2014 - An integral element of this government-to-government relationship is that consultation occurs with federally-recognized … Tribal Consultation Consultation occurs when the AHRQ Director/Deputy Director or their designee, and
  2. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/resources/infotranshsops.pdf
    September 01, 2009 - (More about this item: The difference between this item and D1 is that the mistake occurs in D3 – it … Although the mistake actually occurs, there is no harm to the patient, but there could have been harm
  3. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/situ/simulation_antepart-hemorrhage.docx
    May 01, 2017 - Trigger #3 Large gush of blood occurs. … Trigger #3 Large gush of blood occurs.
  4. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/resources/tools/reduce/antibiotic-faqs.docx
    March 01, 2017 - yeast (Candida) to enter the bladder, but whether or not a symptomatic infection with tissue damage occurs
  5. www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/resources/tools/reduce/antibiotic-faqs.html
    July 01, 2017 - yeast ( Candida ) to enter the bladder, but whether or not a symptomatic infection with tissue damage occurs
  6. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.docx
    May 01, 2017 - A rule-based failure occurs when a person does not carry out a procedure or protocol correctly or chooses … relationship between defects and production pressures—leaving hazards unnoticed until a sentinel event occurs
  7. www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/advance-organizational-safety-strategies-slides.pdf
    June 18, 2024 - An organization-wide patient safety culture survey occurs at least every 2 years using a validated … An organization-wide patient safety culture survey occurs at least every 2 years using a validated … An organization-wide patient safety culture survey occurs at least every 2 years using a validated
  8. www.ahrq.gov/sites/default/files/2025-03/mahajan-manojlovich-report.pdf
    January 01, 2025 - departments (EDs) are particularly vulnerable to making diagnostic errors, because decision making occurs … using questionnaires, allowing individuals to change their opinions through a process of iteration that occurs … from patients and family members.9,10,11,12,13,14,15 They are also acontextual, as if communication occurs
  9. www.ahrq.gov/sites/default/files/wysiwyg/lhs/lhs_case_studies_bsw.pdf
    April 01, 2019 - includes breaking down silos between medical care and community services to prevent disease before it occurs … happen in one-off initiatives and that institutional know-how doesn’t disappear when staff turnover occurs
  10. www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/best-practices/respiratory-slides.pptx
    November 01, 2019 - Moment 1: Distinguishing Aspiration Event From Aspiration Pneumonia Aspiration pneumonia Generally occurs … If rapid improvement occurs, antibiotics can be discontinued.
  11. www.ahrq.gov/hai/tools/cauti-hospitals/toolkit-impl.html
    October 01, 2020 - Catheter-Associated Urinary Tract Infections in Hospital Units: Implementation Guide) When a CAUTI occurs
  12. www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions4.html
    June 01, 2023 - The transmission of this information occurs during the OR-to-ICU handoff.
  13. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/engaging-physicians.pdf
    April 01, 2022 - • When an unprofessional incident occurs, identify a peer (e.g., attending to attending, resident
  14. www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/dataspotlight-anemia-dialysis.pdf
    December 02, 2019 - for hemoglobin production only when a patient’s hemoglobin level is below 10 g/dL.2 Anemia commonly occurs
  15. www.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-fac-notes.html
    December 01, 2017 - The problem occurs when we recoil from cognitive tools, like checklists, because we ARE good at our jobs … ideal target for developing an intervention is a factor that is a major contributor to the defect and occurs … If there is something that occurs rarely but has a singular impact on this particular defect, consider … If the factor is a minor contributor to the defect, but occurs often, then consider intervening on this
  16. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects_facnotes.docx
    December 01, 2017 - The problem occurs when we recoil from cognitive tools, like checklists, because we ARE good at our jobs … ideal target for developing an intervention is a factor that is a major contributor to the defect and occurs … If there is something that occurs rarely but has a singular impact on this particular defect, consider … If the factor is a minor contributor to the defect, but occurs often, then consider intervening on this
  17. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.pdf
    May 01, 2017 - • A rule-based failure occurs when a person does not carry out a procedure or protocol correctly or … relationship between defects and production pressures—leaving hazards unnoticed until a sentinel event occurs
  18. www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-facilitator-guide.docx
    June 01, 2021 - They may not be obvious until a triggering event occurs. … Stasis dermatitis, a condition which occurs because of inadequate function of the venous system, can
  19. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4/mod4-system-focused-event-guide.pdf
    April 01, 2016 - When an adverse event occurs, too often, the focus is on an individual’s performance and is corrected … Event Occurs In-depth Review Confirmation and Consensus Meeting Solutions Meeting Follow Up ■ Activate … Develop targeted solutions ■ Evaluate and measure solutions ■ Finalize event review documents Occurs … within 72 hours after event Occurs within 30-45 business days after the event Occurs at: ■ 30 days … that the organization identify a group of individuals who can be immediately available when an event occurs
  20. www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/improving-fac-notes.html
    May 01, 2017 - looking to enhance your briefing or start a briefing in your facility, remember that a good briefing occurs … One of the most difficult components of performing a debriefing is making sure that it occurs when all … A debriefing that never occurs cannot benefit subsequent patients. … tone by asking team members if they are ready instead of telling them to stop, which is what typically occurs … Say: One of the most important steps in performing a tabletop simulation is the discussion that occurs

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