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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.
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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/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
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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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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/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
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psnet.ahrq.gov/node/39829/psn-pdf
January 09, 2025 - analysis discusses the importance of transparency to motivate progress after a patient safety incident
occurs
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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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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/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
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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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psnet.ahrq.gov/node/60165/psn-pdf
March 25, 2020 - /issue/threat-within-mitigating-risk-medical-error
Despite efforts to protect patients, harm still 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/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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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruprev/saworksheet.docx
June 02, 2025 - changes in care plans, and
Identifies how they carry out root cause analysis when a pressure ulcer occurs … For every meeting that occurs at your facility, indicate how often it occurs, who leads the meeting,
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/warm-handoff-design-guide-final508.pdf
June 02, 2025 - � How the handoff occurs (e.g., in person, through the EHR, through a paper chart). … � Where the handoff occurs (e.g., in the hallway, at the computer workstation, at the
front desk … � When the handoff occurs (e.g., after rooming, after the exam, at the conclusion of the visit).