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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Thomadsen.pdf
December 23, 2004 - Finally, knowledge-based errors happen when a situation is unique
and unknown, for which no rules exist
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/safe-electronic/e-fetal-monitoring_facguide.docx
May 01, 2017 - plan is through briefings and team management, being aware of what is going on and what is likely to happen … other delegated staff speaks to patient and partner regarding the urgency of the situation and what may happen
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursing-home-survey-english-2.0.pdf
June 05, 2025 - ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 9
2
Section B: Communication
How often do the following things happen
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/module3-transcript.pdf
June 01, 2017 - perfect, we take that, and we take it apart, and
we dissect it so thoroughly that that thing won't happen
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/situ/simulation_mg-toxicity.docx
May 01, 2017 - AHRQ Safety Program for Perinatal Care: Sample Scenario for Magnesium Toxicity In Situ Simulation
AHRQ Safety Program for Perinatal Care
Sample Scenario for Magnesium Toxicity In Situ Simulation
Sample Scenario for Magnesium Toxicity In Situ Simulation
Purpose of the tool: The Magnesium Toxicity In Situ Simulation t…
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/situ/simulation-mg-toxicity.html
July 01, 2023 - Sample Scenario for Magnesium Toxicity In Situ Simulation
AHRQ Safety Program for Perinatal Care
Purpose of the tool: The Magnesium Toxicity In Situ Simulation tool provides a sample scenario for labor and delivery (L&D) staff to practice teamwork, communication, and technical skills in the unit …
-
www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/communication-facilitator-guide.docx
June 01, 2021 - This type of communication should always be discouraged, but unfortunately it does happen.
-
www.ahrq.gov/sites/default/files/2025-02/mcneil-report.pdf
January 01, 2025 - Panel 7: "Making Change in Happen in Communities." … complexity of healthcare, achieve consensus on
strategies and goals, and collaborate to make change happen … Making Change Happen in Communities
Moderator: Bruce Siegel, MD, MPH, Director, Center for Health
-
www.ahrq.gov/ncepcr/tools/obesity-kit/obtoolkit1.html
March 01, 2014 - be translatable to any community resource and any practice willing to take the extra step to make it happen
-
www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/ambulatory/6bb-toolkit-fasttrack-complete.pdf
October 01, 2021 - 1
OVERVIEW
The Six Building Blocks: A Team-Based
Approach to Improving Opioid
Management in Primary Care How-To-
Implement Toolkit:
Overview
Prepared for:
Agency for Healthcare Research and Quality
U.S. Department of Health and Human Services
5600 Fishers Lane
Rockville, MD 20857
Contract No. HHSP23320…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/visual/visual-mgmt-component-kit.docx
May 01, 2017 - problems in your safety management that you can tackle (problems are gaps between what you want to happen
-
www.ahrq.gov/sites/default/files/wysiwyg/nhguide/6_TK1_T3-Resident_Information_Sheet_Antibiotic-Resistant_Bacteria_Final.pdf
October 01, 2016 - This can happen when
someone touches you, or by touching something that has the bacteria on it, such
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/situ/simulation_facguide.pdf
May 01, 2017 - correct
diagnosis, appropriate treatment)
• Timeliness—which measures how long
it took for something to happen
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_sr-execs_facnotes.docx
December 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 doesn’t happen without preplanning and a strong and consistent communication process with the entire
-
www.ahrq.gov/hai/tools/surgery/modules/on-boarding/sr-exec-slides.html
December 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 doesn’t happen without preplanning and a strong and consistent communication process with the entire
-
www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/interview-protocol-pcip-staff-ny.pdf
June 02, 2025 - If you want to make a change in this practice how does that happen?
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_sustspreading.pptx
December 01, 2017 - Why did it happen?
How will you reduce the risk of the defect happening again?
-
www.ahrq.gov/sites/default/files/wysiwyg/nhguide/6_TK1_T2-Talking_with_Residents_Family_Members_Final.pdf
October 01, 2016 - An allergic reaction doesn’t
often happen, but sometimes it does.
2. … Side effects happen
sometimes, but usually aren’t too much of a problem.
-
www.ahrq.gov/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/communication/strategy6i-shared-decisionmaking.html
April 01, 2023 - In some cases, clinicians are supportive of the concept but do not know how to make it happen.
-
www.ahrq.gov/sites/default/files/publications/files/sustainability-guide_2.pdf
September 01, 2015 - How To Use This Document
Planning for sustainability should happen early in the process of implementing … Defects”
A defect is any clinical event or situation that a staff member or provider would not want to
happen … Why did it happen?
What will we do to reduce the risk of recurrence?