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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-factraining-guide.docx
June 02, 2025 - We talk to the resident and staff to figure out what happened when that resident fell or how that pressure
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/013-ss-cleaning-fg.docx
April 01, 2025 - They followed the Learning From Defects process to determine what happened and identify contributing
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/survey-methods-research/summary-research-meeting.pdf
January 01, 2019 - education, in that the
purpose of the survey results is to identify systemic issues, not to say what happened
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digital.ahrq.gov/sites/default/files/docs/citation/r01hs022305-manojlovich-final-report-2019.pdf
January 01, 2019 - people to evade face-to-face contact, even as
there may be more need for it, as indicated by what happened
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www.ahrq.gov/sites/default/files/2024-07/hatlie-report.pdf
January 01, 2024 - others or responding to others’ questions about one’s own story can lead to internal reframing of
what happened—a
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psnet.ahrq.gov/node/49528/psn-pdf
January 01, 2015 - The "Customer" Is Always Right
February 1, 2007
Sehgal NL. The "Customer" Is Always Right. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/customer-always-right
Case Objectives
Understand the importance of identifying a patient's agenda.
Appreciate the factors that contribute to unmet patient expectations.
…
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psnet.ahrq.gov/node/49633/psn-pdf
September 01, 2011 - The Safety and Quality of Long Term Care
September 1, 2011
Vogelsmeier AA. The Safety and Quality of Long Term Care. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/safety-and-quality-long-term-care
Case Objectives
Identify commonly reported adverse events in long-term care.
Identify two to three challenges…
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psnet.ahrq.gov/node/33809/psn-pdf
June 01, 2016 - In Conversation With… Gregg S. Meyer, MD, MSc
June 1, 2016
In Conversation With… Gregg S. Meyer, MD, MSc. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-gregg-s-meyer-md-msc
Editor's note: Dr. Meyer is Chief Clinical Officer of Partners Healthcare System, the large Boston-based
system tha…
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psnet.ahrq.gov/node/838855/psn-pdf
October 27, 2022 - False Assumptions Result in a Missed Pneumothorax
after Bronchoscopy with Transbronchial Biopsy.
October 27, 2022
Kuhn BT, Chau-Etchepare F. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy
with Transbronchial Biopsy. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/false-assumptions-resul…
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psnet.ahrq.gov/node/854897/psn-pdf
October 31, 2023 - Weight and Height Juxtaposition in the Electronic Medical
Record Causing an Accidental Medication Overdose
October 31, 2023
Jain NP, Dakwa D. Weight and Height Juxtaposition in the Electronic Medical Record Causing an
Accidental Medication Overdose. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/weight-and-…
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psnet.ahrq.gov/web-mm/hazards-distraction-ticking-all-ehr-boxes
April 09, 2014 - SPOTLIGHT CASE
The Hazards of Distraction: Ticking All the EHR Boxes
Citation Text:
Easty AC. The Hazards of Distraction: Ticking All the EHR Boxes. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Copy Citation
…
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psnet.ahrq.gov/node/49550/psn-pdf
December 01, 2007 - Deaths Not Foretold: Are Unexpected Deaths Useful
Patient Safety Signals?
December 1, 2007
Shojania KG. Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals? PSNet
[internet]. 2007.
https://psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
The Case
…
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www.ahrq.gov/research/findings/final-reports/stpra/stpraapd.html
April 01, 2018 - Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers
Appendix D. Site Visit Process Comparison
Previous Page Next Page
Table of Contents
Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers
Executive Summary
Chapter 1. Introduction
Ch…
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/microbiologic-specimens-facilitator-guide.docx
June 01, 2021 - AHRQ Safety Program for Improving Antibiotic Use
1
Appropriate Collection of Microbiologic Specimens
Long-Term Care
Slide Title and Commentary
Slide Number and Slide
Appropriate Collection of Microbiologic Specimens
Long-Term Care
SAY:
Welcome to this presentation, titled, “Appropriate Collection of Microbiol…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/3-sorra-sops-hospital-survey-2-0-webcast.pdf
July 20, 2020 - AHRQ Webcast Introducing the New SOPS Hospital Survey 2.0 - Sorra
AHRQ Surveys on Patient Safety Culture™
Hospital Survey Version 2.0
Joann Sorra, PhD
Project Director, AHRQ Surveys on Patient Safety Culture User Network, Westat
12
HSOPS 2.0 Development Team
• Westat Research Team:
Theresa Famolaro, MPS, MS, …
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-catheter-removal-notes.docx
April 01, 2022 - Prompting Removal of Unnecessary Indwelling Urinary Catheters Facilitator Notes
CAUTI Module:
Indwelling Urinary Catheter Removal
Facilitator Guide
Slide Number and Image
This module, titled “Indwelling Urinary Catheter Removal,” is part of the Agency for Healthcare Research and Quality’s Safety Program for In…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/rapid-response/rapidresponse_facguide.pdf
May 01, 2017 - AHRQ Safety Program for Perinatal Care: Rapid Response for Perinatal Safety
AHRQ Safety Program for Perinatal Care
Rapid Response for Perinatal Safety
AHRQ Publication No. 17-0003-20-EF
May 2017
SAY:
The Rapid Response for Perinatal Safety
bundle provides information establishing a
unitwide approach, also …
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/tool_shoulder-dystocia.docx
May 01, 2017 - AHRQ Safety Program for Perinatal Care: Labor and Delivery Unit Safety Shoulder Dystocia
AHRQ Safety Program for Perinatal Care
Labor and Delivery Unit Safety
Shoulder Dystocia
Labor and Delivery Unit Safety—Shoulder Dystocia
Purpose of the tool: This tool describes the key perinatal safety elements related to the saf…
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/learn/learn-about-cusp-facilitator-guide.pdf
May 01, 2017 - Learn About the Comprehensive Unit-Based Safety Program for Perinatal Safety
AHRQ Safety Program for Perinatal Care
Learn About the Comprehensive Unit-Based Safety Program for Perinatal Safety
AHRQ Publication No. 17-0003-1-EF
May 2017
SAY:
This module introduces the comprehensive
unit-based safety program, …
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/040-mrsa-surveillance-notes.docx
October 01, 2024 - AHRQ Safety Program for MRSA Prevention
MRSA Surveillance
ICU & Non-ICU
Slide Title and Commentary
Slide Number and Slide
MRSA Surveillance
SAY:
Welcome to this presentation on MRSA Surveillance, which will explain how various approaches to MRSA surveillance help to prevent transmission of MRSA in intensive care u…