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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/situ/simulation-fac-guide.html
July 01, 2023 - Timeliness—which measures how long it took for something to happen (e.g., time to incision).
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www.ahrq.gov/prevention/guidelines/tobacco/clinicians/tearsheets/prenatal.html
October 01, 2014 - Good Things Happen as Soon as You Quit
For Your baby:
Your baby will be healthier.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/clinicians-providers/guidelines-recommendations/tobacco/clinicians/tearsheets/prenatal.pdf
September 01, 2008 - You Can Quit Smoking
GOOD THINGS HAPPEN AS SOON
AS YOU QUIT
FOR YOUR BABY:
Your baby will be healthier
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/resources/asc_pilotstudy.pdf
April 01, 2015 - We are good at changing processes to make sure the same patient safety problems don’t happen again. 90% … We are good at changing processes to make sure the same patient safety problems don’t happen
again. … We are good at changing processes to make sure the same patient safety
problems don’t happen again. … We are good at changing processes to make
sure the same patient safety problems don’t
happen again. … Staff are told about patient safety problems
that happen in this facility.
95% 94% 94% 84% 86% 77%
-
www.ahrq.gov/evidencenow/projects/heart-health/evidence/aspirin.html
March 01, 2021 - Aspirin, Heart Disease, and Stroke
This patient education booklet explains how heart attack and stroke happen
-
www.ahrq.gov/news/blog/ahrqviews/long-covid.html
March 01, 2023 - its National Advisory Council, where we will continue to address these critical matters to make that happen
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/pf-engagement-facilitator-guide.pdf
May 01, 2017 - Medical providers are committed to caring for
their patients; however, adverse events can
happen.
-
www.ahrq.gov/hai/cusp/modules/understand/alt-text.html
July 01, 2018 - central line-associated blood stream infections per year8
Slide 5
How Can These Errors Happen … Why did it happen?
How will you reduce the risk of recurrence?
-
www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module4/mod4-slides.html
March 01, 2017 - N
Next— What will happen next? Anticipated changes? What is the plan? … frontline care providers is to help and care for residents without harming them, but adverse events happen
-
www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/interview-protocol-baseline-sw.pdf
April 04, 2016 - It helps us understand what you talked about if we can
actually see where things happen.
21) Can you … a) Where are any significant bottlenecks that can happen during this process?
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/esrd/using-checklists/checklistandauditslides.pptx
September 03, 2014 - Why did it happen?
What will we do to reduce the recurrence?
How will we know it worked?
… Why did it happen?
Step 1. Visualize the factors that led to the event.
Step 2. … Why did it happen?
3. What will you do to reduce the risk of recurrence?
4.
-
www.ahrq.gov/sites/default/files/publications/files/ltcmodule1.pdf
June 01, 2012 - These situations may happen when a person is
ill, and even more so if that person is frail. … Changes
like this that happen suddenly might be related to their medication, or they may
signal a stroke … But once you’re familiar with daily patterns, you’ll be aware
of the things that happen often and those … Sometimes systems create “an accident waiting to happen.”
-
www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-webinar-jan-2017-schlesinger.pdf
January 01, 2017 - CAHPS Elicitation Protocol Webcast
Development and Testing of
the CAHPS Elicitation Protocol
Mark Schlesinger
Yale School of Public Health
www.ahrq.gov/cahps
Goals for narrative elicitation: specifics
We aspired to collect narratives that are:
• Complete: provide a full picture of the experiences that
matter…
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/2019-pharmacy-sops-database-report-appendix.pdf
January 01, 2019 - We look at staff actions and the way we do things to understand why mistakes
happen in this pharmacy … We look at staff actions and the way we do things to understand why
mistakes happen in this pharmacy … We look at staff actions and the way we do things to understand
why mistakes happen in this pharmacy … We look at staff actions and the way we do things to
understand why mistakes happen in this pharmacy
-
www.ahrq.gov/sites/default/files/2024-01/gallagher2-report.pdf
January 01, 2024 - .
4 1:30 min MD-2
RN-0
MD: And I want to let you know that I am terribly sorry that you had this happen … So, we actually
don’t have the specimen, and we’re sorry….And things like this unfortunately [do]
happen … There’s just no way that can happen
otherwise.”
Med RN: “That it is okay to apologize. … an equal member of the
healthcare team, then they need to be equally accountable for errors
that happen
-
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
-
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.
-
www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/medical-office/2014/mosurv14notes.html
June 01, 2014 - For example, for the item "Mistakes happen more than they should in this office," if 60 percent of respondents … percent positive response would be 80 percent (i.e., 80 percent of respondents do not believe mistakes happen
-
www.ahrq.gov/talkingquality/plan/manage.html
November 01, 2018 - Establishing a Management Structure
Quality reporting projects do not happen by themselves.
-
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…