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  1. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/learn-from-defects-slides.pptx
    January 01, 2017 - Presentation: Program Overview Learn From Defects in Care of Mechanically Ventilated Patients AHRQ Safety Program for Mechanically Ventilated Patients AHRQ Pub. No. 16(17)-0018-34-EF January 2017 Learn From Defects ‹#› AHRQ Safety Program for Mechanically Ventilated Patients 1 Learning Objectives After this ses…
  2. www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-cognitive-load1.html
    May 01, 2024 - Cognitive Load Theory and Its Impact on Diagnostic Accuracy Introduction to Diagnostic Errors Previous Page Next Page Table of Contents Cognitive Load Theory and Its Impact on Diagnostic Accuracy Introduction to Diagnostic Errors Fundamental Concepts for Understanding Cognitive Load Interplay …
  3. www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes6.html
    August 01, 2022 - Module 6: Care for the Caregiver AHRQ Communication and Optimal Resolution Toolkit Facilitator Notes Say: Module 6 includes information on the Care for the Caregiver component of the CANDOR process, which focuses on providing emotional support to caregivers following a CANDOR event. This module …
  4. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module6/module6-care-for-caregiver.pptx
    May 01, 2011 - PowerPoint Presentation Communication and Optimal Resolution (CANDOR) Toolkit Module 6: Care for the Caregiver Module 6 includes information on the Care for the Caregiver component of the CANDOR process, which focuses on providing emotional support to caregivers following a CANDOR event. This module includes steps…
  5. www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/reportguide.html
    November 01, 2017 - AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention Training Facilitator Training Instructor Guide Slide 1: Introduction to Falls Reports AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention Facilitator Training Introduction to Falls Reports Say: In this session we will in…
  6. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Gallagher1.pdf
    January 01, 2004 - This occurs when a Advances in Patient Safety: Vol. 2 30 patient has a primary diagnosis of accidental … One of the primary procedures that occurs often in this PSI is hysterectomy.
  7. www.ahrq.gov/sites/default/files/2024-09/weissman-report.pdf
    January 01, 2024 - Final Progress Report: Weekend Effects and the July Phenomenon in Patient Safety --------------------------------------- Weekend Effects and the July Phenomenon in Patient Safety Final Research Report to AHRQ Principal Investigator: Joel S. Weissman, PhD February 6, 2006 Co-Investigators and Study Staff (i…
  8. www.ahrq.gov/sites/default/files/2024-11/devita-report.pdf
    January 01, 2024 - teams, because the intent is to respond to acute patient deterioration before a cardiopulmonary arrest occurs
  9. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/111-ss-cusp-lfd-worksheet-a3.docx
    April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI Investigating a Defect Worksheet Surgical Services For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion SurgeriesOwner: ____________________________ Date Defect Occurred: ________________ Date Investigation Initiated: ___________ Use the Learning From …
  10. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-surgery/111-cusp-learning-from-defects-worksheet.docx
    April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI Investigating a Defect Worksheet Surgical Services For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion SurgeriesOwner: ____________________________ Date Defect Occurred: ________________ Date Investigation Initiated: ___________ Use the Learning From …
  11. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/066-dec-staff-faqs-safety-side-effects.docx
    October 01, 2024 - AHRQ Safety Program for MRSA Prevention Decolonization: Staff Frequently Asked Questions Safety & Side Effects This document provides questions and answers to commonly asked questions. Some questions and answers may not be relevant to your unit. You should remove or edit information to match your unit’s protocols. The…
  12. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Potter.pdf
    January 01, 2003 - An Analysis of Nurses' Cognitive Work: A New Perspective for Understanding Medical Errors 39 An Analysis of Nurses’ Cognitive Work: A New Perspective for Understanding Medical Errors Patricia Potter, Laurie Wolf, Stuart Boxerman, Deborah Grayson, Jennifer Sledge, Clay Dunagan, Bradley Evanoff Abstract He…
  13. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/1_preventablehospitaledvisits-overview-ig.pdf
    June 02, 2025 - It also asks which staff members are invited, who leads the meeting, and how often it occurs. … plans; • Discuss care changes that are needed; and • Investigate root causes when an adverse event occurs
  14. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Mohr.pdf
    February 01, 2004 - Wasserman, Lynne Uhring Abstract Background: Approximately 70 percent of pediatric care occurs in
  15. www.ahrq.gov/healthsystemsresearch/hspc-research-study/conclusions.html
    July 01, 2021 - In addition, such research often occurs in highly controlled conditions or atypical settings that are … However, no overall prioritization of HSR agendas occurs across agencies, except on a limited number … coordination once redundancies are recognized, but that identification of potential overlaps in portfolios occurs
  16. www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/pf-engagement-slides.html
    July 01, 2023 - When an adverse event occurs, it can be difficult for a health care worker to take ownership and communicate
  17. www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/situ/sim-tool-guidance.html
    July 01, 2023 - The most powerful learning occurs during debriefing, when participants have a chance to review their
  18. www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions2.html
    June 01, 2023 - Finally, admission occurs early in a patient’s hospital course, when patients may be medically unstable
  19. www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/pharyngitis-slides.pptx
    September 01, 2022 - cefadroxil No reported resistance Severe penicillin allergy Clindamycin or azithromycin Resistance occurs
  20. www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/bronchitis-guide.docx
    September 01, 2022 - Not Improve Post-Viral Cough SAY: Antibiotics do not hasten the resolution of acute bronchitis that occurs

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