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1. Module 2: Example (doc file)
   www.innovations.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/visual/visual-mgmt-pdsa-form.docx
   May 01, 2017 - reviewed during huddle; if huddle is not scheduled regularly yet, let all relevant staff know huddle will happen … Predict what will happen when the test is carried out (e.g., if we do “x,” “y” will happen) Measures … When to be done Where to be done Predict what will happen … when the test is carried out (i.e., if we do “x,” “y” will happen) Measures to compare prediction

2. Survey on Patient Safety (facility version) (doc file)
   www.innovations.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.doc
   November 15, 2019 - It is just by chance that more serious mistakes don’t happen around here (1 (2 (3 (4 (5 11. … My supervisor/manager overlooks patient safety problems that happen over and over (1 (2 (3 (4 ( … 5 SECTION C: Communications How often do the following things happen in your work area/unit? … We are informed about errors that happen in this unit (1 (2 (3 (4 (5 4. … (5 SECTION D: Frequency of Events Reported In your work area/unit, when the following mistakes happen

3. Hospital Survey on Patient Safety (doc file)
   www.innovations.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.doc
   June 09, 2016 - It is just by chance that more serious mistakes don’t happen around here (1 (2 (3 (4 (5 11. … My supervisor/manager overlooks patient safety problems that happen over and over (1 (2 (3 (4 ( … 5 SECTION C: Communications How often do the following things happen in your work area/unit? … We are informed about errors that happen in this unit (1 (2 (3 (4 (5 4. … SECTION D: Frequency of Events Reported In your hospital work area/unit, when the following mistakes happen

4. Hospital Survey on Patient Safety (pdf file)
   www.innovations.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.pdf
   December 22, 2017 - It is just by chance that more serious mistakes don’t happen around here ......................... … My supervisor/manager overlooks patient safety problems that happen over and over ................. … 1 2 3 4 5 3 SECTION C: Communications How often do the following things happen in your … We are informed about errors that happen in this unit .............................. … SECTION D: Frequency of Events Reported In your hospital work area/unit, when the following mistakes happen

5. Hospital Survey on Patient Safety (pdf file)
   www.innovations.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/resources/hospscanform.pdf
   March 22, 2017 - It is just by chance that more serious mistakes don’t happen around here ......................... … My supervisor/manager overlooks patient safety problems that happen over and over ................. … 1 2 3 4 5 3 SECTION C: Communications How often do the following things happen in your … We are informed about errors that happen in this unit .............................. … SECTION D: Frequency of Events Reported In your hospital work area/unit, when the following mistakes happen

6. Sample “Plan-Do-Study-Act” Form | Agency for Healthcare Research and Quality
   www.innovations.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/management/huddles-pdsa-form.html
   June 01, 2017 - Where will huddle happen? Default: In front of the visual management board       9.  … Predict what will happen when the test is carried out  (e.g., if we do “x,” “y” will happen) Measures …                     Predict what will happen … when the test is carried out (i.e., if we do “x,” “y” will happen) Measures to compare prediction

7. Sample “Plan-Do-Study-Act” Form | Agency for Healthcare Research and Quality
   www.innovations.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/management/pdsa-form.html
   June 01, 2017 - reviewed during huddle; if huddle is not scheduled regularly yet, let all relevant staff know huddle will happen … Predict what will happen when the test is carried out  (e.g., if we do “x,” “y” will happen) Measures …                     Predict what will happen … when the test is carried out (i.e., if we do “x,” “y” will happen) Measures to compare prediction

8. An Update on the CAHPS Patient Narrative Item Sets - Martino (pdf file)
   www.innovations.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-patient-narrative-martino.pdf
   June 01, 2021 - An Update on the CAHPS Patient Narrative Item Sets - Martino UPDATED NARRATIVE ITEM SETS FOR THE CAHPS CLINICIAN & GROUP SURVEY Steven Martino, PhD Overview of Narrative Item Set Development Process • Literature review and environmental scan • Drafting of narrative items • Pretesting to assess readability and …

9. An Update on the CAHPS Patient Narrative Item Sets - Schlesinger (pdf file)
   www.innovations.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-patient-narrative-schlesinger.pdf
   December 14, 2021 - An Update on the CAHPS Patient Narrative Item Sets - Schlesinger PREVIEW OF NEW NARRATIVE ITEM SETS IN DEVELOPMENT Mark Schlesinger, PhD A Growing Family of Narrative Item Sets CG-CAHPS Narrative Item Set Health Plan Narrative Item Set Inpatient Narrative Items: For Child HCAHPS 19 The Health Plan Narr…

10. Mod5-Disclosure-Checklist (pdf file)
    www.innovations.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/mod5-disclosure-checklist.pdf
    April 01, 2016 - Purpose: To provide guidance to individuals who are conducting initial or followup disclosure conversations, including key disclosure communication skills. Who should use this tool? Disclosure Lead and any staff who will be engaged in disclosure conversations. How to use this tool: Use Part I of the checklist to pre…

11. 20 Tips To Help Prevent Medical Errors: Patient Fact Sheet | Agency for Healthcare Research and Quality
    www.innovations.ahrq.gov/questions/resources/20-tips.html
    November 01, 2020 - They can happen during even the most routine tasks, such as when a hospital patient on a salt-free diet … But errors also happen when doctors * and patients have problems communicating. … If you know what might happen, you will be better prepared if it does or if something unexpected happens

12. Sensemaking and Learn from Defects for Perinatal Safety (pdf file)
    www.innovations.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.pdf
    May 01, 2017 - • Why did it happen? • What will you do to reduce risk? … • Skill-based failures happen when a Slide 4 Sensemaking and Learn From Defects for Perinatal … The consequent event is described in terms of the event’s consequences: • Harm that did happen • … Why did it happen? • Step 1. Visualize the factors that led to the event. • Step 2. … • Defects are clinical or operational events that you do not want to happen again.

13. Hospital Survey on Patient Safety Culture Version 2.0: Composites and Items (pdf file)
    www.innovations.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospitalsurvey2-items.pdf
    August 01, 2019 - We are informed about errors that happen in this unit. C2. … When errors happen in this unit, we discuss ways to prevent them from happening again. C3.

14. Implementation Guide Appendix J Coaching Tool Instructions and Observation Tool With Coaching Section (pdf file)
    www.innovations.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/implementation-guide/appendix-j.pdf
    April 13, 2017 - Implementation Guide Appendix J Coaching Tool Instructions and Observation Tool With Coaching Section AHRQ Safety Program for Ambulatory Surgery Appendix J. Coaching Tool Instructions and Observation Tool With Coaching Section After using the observation tool to collect information regarding the processes perfor…

15. Using Mass Media To Spread Messages About a Quality Report | Agency for Healthcare Research and Quality
    www.innovations.ahrq.gov/talkingquality/distribute/promote/multiple/using-media.html
    September 01, 2019 - Bad press can happen because the people you worked with didn’t take the time to understand your work, … While any of these misfortunes can happen, they are not reasons to avoid working with the media entirely … Bad press can happen to anyone.

16. Public Reporting of Patients' Comments with Quality Measures: How Can We Make It Work? (pdf file)
    www.innovations.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/20140603_QI/3_rachel_grob.pdf
    June 25, 2014 - past 12 months) Positive experiences: 1 Question with narrative guide (what happened, how did it happen … (past 12 months) Positive experiences: 1 Question with narrative guide (what happened, how did it happen

17. Sensemaking and Learn From Defects for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
    www.innovations.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-fac-guide.html
    July 01, 2023 - Why did it happen? What will you do to reduce risk? … The consequent event is described in terms of the event's consequences: Harm that did happen. … Harm that did not happen—No-harm event. Event did not reach the patient—Near-miss event. … Why did it happen? Step 1. Visualize the factors that led to the event. Step 2. … Defects are clinical or operational events that you do not want to happen again.

18. Understand the Science of Safety for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
    www.innovations.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/understand-sci-fac-guide.html
    July 01, 2023 - Slide 4: How Can These Errors Happen? … The first step in comprehending why they happen is accepting that people are not perfect. … Why did it happen? What will we do to reduce the recurrence? How will we know it worked? … Why did it happen? How will you reduce the risk of recurrence? How will you know it worked?

19. Implementing the New CAHPS® Protocol for Obtaining Patient Comments About Their Care (pdf file)
    www.innovations.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/nyp-webinar-grob-narrative-elicitation-protocol.pdf
    October 29, 2018 - Implementing the New CAHPS® Protocol for Obtaining Patient Comments About Their Care The CAHPS Narrative Elicitation Protocol Rachel Grob, Ph.D. Director of National Initiatives and Clinical Professor, Center for Patient Partnerships Madison, WI www.ahrq.gov/cahps CAHPS Narrative Elicitation Protocol • A …

20. Communication and Optimal Resolution (CANDOR) Toolkit | Agency for Healthcare Research and Quality
    www.innovations.ahrq.gov/patient-safety/settings/hospital/candor/modules.html
    August 01, 2022 - Module 7: Resolution Module 8: Organizational Learning and Sustainability “We realize mistakes happen … Harms such as hospital-acquired infections or medication errors can happen during any stage of care.