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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Donaldson_87.pdf
April 23, 2008 - complicated when individuals within the
organization—the very people charged with making the change happen—are … • “Systems savvy,” i.e., experience and knowledge with making things happen within a
nursing service
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Zierler_81.pdf
September 01, 2008 - developed within the framework proposed by
Greenhalgh, et al.,26 and is positioned between the “help it happen … ” and the “make it happen”
ends of the continuum.
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digital.ahrq.gov/sites/default/files/docs/publication/uc1hs015270-hayden-final-report-2008.pdf
January 01, 2008 - about changes put into place based on event
reports
50% 43% 45%
We are informed about errors that happen … Administration errors: Administration errors are those that happen during the process of
giving the
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digital.ahrq.gov/sites/default/files/docs/citation/r21hs024767-yen-final-report-2019.pdf
January 01, 2019 - […] They were in support of that, because ultimately, what will happen people will
get used to the layout
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www.ahrq.gov/sites/default/files/wysiwyg/mcc/pccp4p/measures-rapid-scan-report.pdf
April 10, 2025 - These measures acknowledge that
implementation of a new practice usually does not happen all at once … Documenting PCCP also takes time, and this documentation might not happen during the visit. … I’d love to hear your experience with this, or your thoughts
about how this could happen.
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www.ahrq.gov/sites/default/files/publications2/files/guide-to-real-world-evaluations.pdf
October 01, 2014 - A Guide to Real-World Evaluations of Primary Care Interventions: Some Practical Advice
c
Agency for Healthcare Research and Quality
Advancing Excellence in Health Care www.ahrq.gov
The PCM Portfolio graphic element is intended to be closely aligned with AHRQ's overall brand, while also
Chronic Care Model.…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/ltvv-mvpguide.pdf
January 01, 2017 - provides a detailed process to improve your systems.82, 84, 85 A defect is
anything you do not want to happen … • 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/systems/hospital/pressureulcertoolkit/putoolssect7.docx
February 16, 2011 - What will happen? … describe key processes in your organization where pressure ulcer prevention activities could or should happen
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psnet.ahrq.gov/node/33809/psn-pdf
June 01, 2016 - When I think
back to my days at AHRQ, we had a fantasy that something like this would begin to happen
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psnet.ahrq.gov/web-mm/discharged-iv-antibiotics-when-issues-arise-who-manages-complications
October 10, 2017 - They need to be aware of what may happen and when to reach out to their physician or go to the emergency
-
www.ahrq.gov/sites/default/files/2024-07/seid-sobo-report.pdf
January 01, 2024 - I’m the doctor, I
am telling you this is what is going to happen and this is how it’s going to be.”
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psnet.ahrq.gov/perspective/conversation-ann-l-hendrich-rn-phd
February 26, 2025 - on these high beds with a step stool beside it and that actually becomes like an accident waiting to happen
-
www.ahrq.gov/sites/default/files/2024-04/wolfson-report.pdf
January 01, 2024 - The survey asked respondents to list follow-
up activities they would like to see happen, which generated
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/medicaidmgmt/mm6.html
October 01, 2014 - Predict what will happen and why.
Develop a plan to test the change (Who? What? When? Where?
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-catheter-removal-notes.docx
April 01, 2022 - So why does this happen? Let’s review the traditional steps for removing a catheter.
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www.ahrq.gov/hai/cauti-tools/cauti-icu/facil-guide/mod1.html
February 01, 2023 - How many happen every year?
What is his/her unit’s approach to catheter use?
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psnet.ahrq.gov/node/33805/psn-pdf
April 01, 2016 - to come together because of the other pressures in
the environment, or CLER is actually making that happen
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psnet.ahrq.gov/web-mm/hazards-distraction-ticking-all-ehr-boxes
April 09, 2014 - How then did it happen, and what are the implications for the use of checklists and order sets in medicine
-
psnet.ahrq.gov/web-mm/right-left-neither
November 16, 2022 - Performing an invasive procedure on the wrong patient should never happen.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-King_1.pdf
April 07, 2008 - Phase II: Planning, training, and implementation – Decide what to do
and make it happen. … Phase II: Planning, training, and implementation – Decide what to do and make it happen.