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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
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www.ahrq.gov/research/publications/search.html?page=17
October 01, 2011 - Safety Tips for Hospitals
Medical errors may occur in different healthcare settings, and those that happen
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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.
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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.
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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
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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?
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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.
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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
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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.
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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…
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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…
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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?
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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
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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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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
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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 .................................…
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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?
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www.ahrq.gov/workingforquality/events/webinar-introducing-nine-levers-to-support-the-aims-and-priorities.html
November 01, 2016 - go in-depth on each one of these, but as a whole, the levers represent actions that we feel need to happen … We have a way to go to design systems that can make that happen. … Then it's about bringing together the different actors to enable the improvement to happen through technical
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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
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www.ahrq.gov/sites/default/files/wysiwyg/lhs/lhs_case_studies_denver_health.pdf
April 01, 2019 - Both committees reinforce the health system’s recognition that improvements
can happen in big and small