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  1. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-surgery/105-what-are-the-4-es-notes.docx
    April 01, 2025 - Discuss in detail goals and what will need to happen to get the best results. … prevent MRSA and SSIs, it is important to standardize care, create independent checks, and when mistakes happen
  2. www.ahrq.gov/hai/cusp/modules/patient-family-engagement/notes.html
    September 01, 2013 - Medical providers are committed to caring for their patients; however, adverse events can happen.
  3. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/engaging-srexec-facguide.docx
    January 01, 2017 - is much easier to engage someone (anyone, not just executives) if you can be clear about what will happen … The CUSP components of this safety program can be a way to make this happen in a structured, predictable … This does not happen without preplanning and a strong and consistent communication process with the entire
  4. www.ahrq.gov/talkingquality/translate/labels/measures.html
    July 01, 2016 - Label Health Care Quality Measures in Plain English   The public does not speak the same language as health professionals. To reach the public, you will have to translate many terms that are common in the health world into the language of lay people. This includes not only medical terms but also those that po…
  5. www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/gdmodap3a.html
    October 01, 2014 - Fixing "accidents waiting to happen." Expecting teamwork. Slide 6 Is it a fall?
  6. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/016-ss-hand-hygiene-periop.pptx
    April 01, 2025 - Why did it happen? How to reduce the likelihood of this defect from happening again? … MRSA Prevention | Surgical Services Hand Hygiene in the Perioperative Setting Case Example: Why Did It Happen
  7. www.ahrq.gov/workingforquality/events/webinar-best-practices-to-improve-community-health.html
    November 01, 2016 - huge networks of community health workers develop across the country and some really amazing things happen … And I think that sometimes that happens when conversations happen about gun and gun violence.
  8. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_sustspreading_facnotes.docx
    December 01, 2017 - Why did it happen? 3. How will you reduce the risk of the defect happening again? 4.
  9. www.ahrq.gov/hai/tools/surgery/modules/sustainability/spreading-fac-notes.html
    December 01, 2017 - Why did it happen? How will you reduce the risk of the defect happening again?
  10. www.ahrq.gov/hai/cauti-tools/facil-guide/preventing-cauti-icu-setting-module2-speaker-notes.html
    February 01, 2023 - In this scenario, the transporter didn’t understand what might happen because of wrong bag placement
  11. www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/2023-ASC-Database-Report-II.pdf
    January 01, 2023 - 92% 91% 90% We are good at changing processes to make sure the same patient safety problems don’t happen … (Item C4) 87% 84% 85% 84% 81% Staff are told about patient safety problems that happen in this facility … (Item C4) 89% 82% 84% 82% 85% 84% 85% 84% 83% Staff are told about patient safety problems that happen … Item C4) 86% 98% 82% 97% 95% 80% 78% 71% 76% Staff are told about patient safety problems that happen … (Item C4) 92% 84% 79% 90% Staff are told about patient safety problems that happen in this facility
  12. www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/ambulatory/6bb-toolkit-fasttrack.pdf
    January 12, 2021 - Six Building Blocks How-To-Implement Toolkit: Fast Track Approach Guide A Team-Based Approach to Improving Opioid Management in Primary Care Table of Contents Introduction ......................................................................................................................................1 W…
  13. www.ahrq.gov/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/customer-service/strategy6q-custservice-standards.html
    March 01, 2020 - Sets clear expectations for what is supposed to happen in encounters.
  14. www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/cooperative-context-external.pdf
    January 01, 2016 - Coop_Context_Info_Assessment COOPERATIVE CONTEXT ASSESSMENT INFORMATION Round 2: External Support What is the importance of context? Cooperatives’ initiatives are taking place in different settings, and each cooperative has a variety of different partners and stakeholders involved. Understanding these project…
  15. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/booklets/laparotomy-patient.pdf
    November 01, 2023 - Program for Improving Surgical Care and Recovery Emergency Laparotomy Surgery When surgery needs to happen … To understand what may happen during surgery, let’s take a look at some diagrams of the belly area. … And things may happen very fast.
  16. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy1/Strat1_Tool_9_AdvisorTrain_508.docx
    March 06, 2013 - If you do share someone else’s story, let people know that this experience did not happen to you and … That can happen when you are working as an advisor, too. … What do you hope will happen as a result of me sharing my story? Who is the audience? … One way to identify areas for improvement is to look at whether the right things happen as part of our
  17. www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/item-sets/elicitation/about-patient-narratives-elicitation-protocol-cg30-2315.pdf
    April 24, 2018 - About the CAHPS Patient Narratives Elicitation Protocol CAHPS® Clinician & Group Survey and Instructions About the CAHPS Patient Narrative Elicitation Protocol Document No. 2315 Updated April 24, 2018 About the CAHPS® Patient Narrative Elicitation Protocol Introduction .................................…
  18. www.ahrq.gov/hai/tools/mrsa-prevention/toolkit/vap.html
    October 01, 2024 - Non-Ventilator Hospital-Acquired Pneumonia VHA: Hospital Acquired Pneumonia Prevention by Engaging Nurses (HAPPEN
  19. www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/implementing-new-protocol-transcript.pdf
    October 01, 2018 - the scenario or the care provision that’s being described, what actually happened and where did it happen … When did it happen? And what was the periodicity?
  20. www.ahrq.gov/funding/grantee-profiles/grtprofile-gurses.html
    November 01, 2023 - “It’s hard to predict what will happen next.

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