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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-trache.pdf
June 02, 2025 - – Usually occurs just superior to the internal stoma site on the anterior tracheal wall. … ■ Persistent tracheocutaneous fistula
– Occurs in up to 40% of children post-decannulation.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-sleep.pdf
June 02, 2025 - Sleep States
■ Active sleep
– Respiration is uneven and primarily costal in nature; REM occurs intermittently
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/understand/scisafety.pptx
March 01, 2009 - many viewpoints as possible
Alternate between convergent and divergent thinking
Divergent thinking occurs … brainstorming sessions, and when trying to understand what might be occurring10
Convergent thinking occurs
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-science-safety.pptx
May 01, 2017 - many viewpoints as possible
Alternate between convergent and divergent thinking7
Divergent thinking occurs … during brainstorming sessions and when trying to understand what might be occurring
Convergent thinking occurs
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www.ahrq.gov/ncepcr/about/impact-stories.html
April 01, 2025 - collected electronic health record (EHR) data to help predict and prevent clinician burnout before it occurs
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/module1-overview.pptx
June 02, 2025 - Module 1
5
When a CANDOR event occurs, the CANDOR process can be used to introduce a number of actions … Module 1
8
Now that we understand the definition of a CANDOR event, let’s briefly examine what occurs … After the CANDOR System Activation occurs, the 3rd and 4th components should occur simultaneously.
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/understand-sci-slides.html
July 01, 2023 - Alternate between convergent and divergent thinking 7
Divergent thinking occurs during brainstorming … Convergent thinking occurs while formulating a treatment plan or focusing on a specific task.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/041-pros-cons-mrsa-surveillance-one-pager.docx
October 01, 2024 - MRSA prevalence among their specific patient population and understand when and where transmission occurs
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-apnea.pdf
June 02, 2025 - ■ Can persist for many weeks in very preterm infants, although resolution typically occurs by 37-
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-vision.pdf
June 02, 2025 - – Plus disease: occurs when arrested blood vessel growth resumes abnormally, with
tortuous vessels
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Comden.pdf
January 01, 2003 - Event50
Facility hears correct dose and
writes wrong dose on order
Q:0.001
Gate363
Read back occurs … and fails
Q:0.28
Event593
Read back does not occur
Q:0.2
Gate483
Read back occurs and fails
Q … and fails
Q:0.28
Event593
Read back does not occur
Q:0.2
Gate483
Read back occurs and fails
Q … Borrowing also occurs when insurer
preauthorization policies delay acquisition of clinically important … Advances in Patient Safety: Vol. 2
404
Sometimes borrowing occurs to avoid surveyor citations for
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb.pdf
June 02, 2025 - ■ Anemia is more profound and occurs earlier in premature infants due to:
– Blood loss from sampling … – Yearly renal ultrasounds until resolution occurs. … Followup
■ A high rate of spontaneous closure occurs during the first 2 years of life. … – Usually occurs just superior to the internal stoma site on the anterior tracheal wall. … – Most significant growth occurs between 36-40 weeks postmenstrual age.
-
www.ahrq.gov/research/findings/final-reports/stpra/stpraref.html
April 01, 2018 - Assessing patient safety risk before the injury occurs: An introduction to sociotechnical probabilistic
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www.ahrq.gov/hai/tools/clabsi-cauti-icu/assess/index.html
April 01, 2022 - thoughtful statement (the Aim) that will guide the team in its actions and can be adjusted as change occurs
-
www.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-slides.html
December 01, 2017 - X-axis begins with "occurs rarely" and moves to "occurs often." … Good target for intervention is marked in the far upper quadrant ("occurs often" and "major reason why … defect occurs").
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/handouts3.html
December 01, 2017 - For every meeting that occurs at your facility, indicate how often it occurs, who leads the meeting,
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/nursing-protocols/nursing-practice-guide.docx
March 01, 2022 - .*
CHG bath documentation occurs once per calendar day
Provide staff educational huddles for central
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www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/nursing-protocols/nursing-practice-guide.pdf
March 01, 2022 - .*
• CHG bath documentation
occurs once per calendar day
• Provide staff educational
huddles
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-assessment.docx
June 02, 2025 - Evaluate once a week and whenever a change occurs in the wound. … As healing occurs in dark-skinned persons, the new skin is pink and may never darken. … In full thickness wounds it occurs from the edges only.
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/action-plan-template.docx
April 01, 2022 - The use of this worksheet will make this possible, and it then can be adjusted as change occurs in the