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psnet.ahrq.gov/node/73552/psn-pdf
August 04, 2021 - related actions that aid in rebuilding trust between clinicians, patients, and
families when error occurs
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psnet.ahrq.gov/node/60563/psn-pdf
June 03, 2020 - last-responders-seek-expand-postmortem-covid-testing-unexplained-deaths
Post-mortem examination is an important tool for determining if misdiagnosis occurs
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psnet.ahrq.gov/node/865588/psn-pdf
April 17, 2024 - https://psnet.ahrq.gov/issue/inattentional-blindness-medicine
Inattentional blindness occurs when a
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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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hcup-us.ahrq.gov/datainnovations/clinicaldata/File1_AHCA_Presentation_To_AHSS_On_POA.jsp
August 01, 2011 - "Present on Admission"
Defined in rule as: "Present at the time an order for inpatient admission occurs … 6
POA Actual Indicators
Y = Yes - Present at the time that the order for inpatient admission occurs … N = No - Not present at the at the time that the order for inpatient admission occurs.
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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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psnet.ahrq.gov/node/48182/psn-pdf
August 21, 2019 - organizational learning in hospitals, including contextual factors that affect it, how such learning occurs
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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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psnet.ahrq.gov/node/42242/psn-pdf
September 06, 2018 - World Sepsis Day occurs yearly on September 13th.
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psnet.ahrq.gov/node/859352/psn-pdf
December 20, 2023 - clinicians, health system leaders, and
improvement experts to discuss actions after medical error occurs
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psnet.ahrq.gov/node/867683/psn-pdf
March 05, 2025 - ambulatory-medication-errors-and-adverse-events-involved-medicine-related-
malpractice-cases
Most medication safety research occurs
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psnet.ahrq.gov/node/73245/psn-pdf
May 12, 2021 - just-culture-foundation-staff-safety-perioperative-environment
A just culture balances organizational and individual accountability when a medical error occurs
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psnet.ahrq.gov/node/850929/psn-pdf
June 21, 2023 - “just culture” balances organizational responsibility and individual accountability after an error occurs
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psnet.ahrq.gov/node/838031/psn-pdf
September 13, 2022 - needed to ensure that patients can trust the health care system to
hold those accountable when error occurs