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  1. 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
  2. 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
  3. 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
  4. 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
  5. 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…
  6. 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 …
  7. 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.
  8. 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
  9. 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
  10. 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…
  11. 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
  12. 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
  13. 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
  14. 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
  15. 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
  16. 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?
  17. 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?
  18. 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.
  19. 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.
  20. 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?

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