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  1. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/warm-handoff-guide-for-clinicians.pdf
    June 02, 2025 - Warm handoffs can help address communication issues and: ■ Engage patients and families and encourage … � Medication issues (e.g., refills, side effects). � Updates on reports: ¤ Labs. ¤ Imaging.
  2. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/128-what-are-4es-one-pager.docx
    April 01, 2025 - Equip staff with knowledge and skills to implement interventions effectively and identify potential issues … dynamic approach and make adjustments in real-time. · Meet regularly to review performance, discuss issues
  3. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/124-cusp-science-safety-fg.docx
    April 01, 2025 - Slide 6 The Four Principles of the Science of Safety SAY: To address the issues in healthcare safety … Ask challenging questions to uncover the real issues and ensure all viewpoints are considered. … Teams should be vigilant and proactive in an effort to anticipate potential problems or issues. … HROs aim to be proactive, not reactive, by addressing issues before they escalate. … Aim for a proactive approach to issues, rather than a reactive one.
  4. www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/Telediagnosis-brief2.pdf
    August 03, 2020 - As such, telediagnosis services that only focus on access issues and ignore how individuals in vulnerable … A host of macro and micro issues may affect these outcomes (Figure 1). … Evaluation of these issues from a formal sociotechnical perspective will be essential to account for … factors impacting telediagnosis (tele-dx) Technology Patient Engagement Clinical PresenceMacro issues … • It can be difficult to discuss issues of violence or abuse if the patient cannot complete the visit
  5. www.ahrq.gov/news/events/nac/2021-03-nac/nacmtg031821-minutes.html
    July 01, 2021 - Cohen reported on AHRQ activities in data and analytics: Responding to the issues of privacy and … There are serious issues, such as a feeling of isolation among nursing home staffs and resulting burnout … She then presented issues within AHRQ’s support for patient-centered outcomes research (PCOR), beginning … Robinson encouraged the NAC members to use the AHRQ blog to discuss further the issues of equity. … AHRQ could inform the legislators on issues such as quality measurement.
  6. www.ahrq.gov/data/qualityindicators/index.html
    January 01, 2025 - ) help hospitals assess the incidence of adverse events and in-hospital complications and identify issues … Pediatric Quality Indicators (PDIs) help detect issues in pediatric hospital care that may need further … preventive care for children in outpatient settings by identifying potential quality and patient safety issues
  7. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-impsteps.pdf
    June 02, 2025 - Step 11: Pilot All Report/Meeting Strategies in One Unit The team discusses implementation issues with … The facilitator will help the team during the next 3 months to address implementation issues until all … , the facilitator’s role is to check in to identify obstacles that could occur and to troubleshoot issues … such as turnover of key staff, computer glitches, and implementation issues.
  8. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/090-decolonization-implementation.pptx
    April 01, 2025 - fusion surgeries Identify key strategies for MRSA decolonization ​ Identify challenges and operational issues … for MRSA Prevention | Surgical Services Decolonization Implementation 7 Challenges and Operational Issues … When making the reminder call before surgery, staff noted that many patients were having issues getting … Not all pharmacies kept CHG cloths in stock No issues getting mupirocin | 16 Case Example AHRQ Safety
  9. www.ahrq.gov/talkingquality/plan/manage.html
    November 01, 2018 - enforce decisions, hire and manage contractors, negotiate terms, and handle all the large and small issues … Some sponsors have spent considerable time and money at this stage in the process to respond to issues
  10. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-retention.pdf
    April 01, 2022 - Barriers • Lack of understanding of the unique catheter-based issues higher acuity neurocritical care … of adjustment to bladder scanning protocols and use of alternative devices for neurologic specific issues … • On admission and during multiprofessional rounds, identify and address specific issues that place … Although most of the strategies in this tip sheet focus on CAUTI-related issues, many can be adapted
  11. www.ahrq.gov/sites/default/files/2024-04/etchegaray-report.pdf
    January 01, 2024 - We brought patient safety culture experts together in a 1-day conference to discuss these issues. … After his presentation, the key discussions were focused on the following issues: Implications for … The discussion focused on each of these three surveys and the following key issues: • SOPS 2.0: Dr … We need to consider how safety issues get used in political battles in the hospital. … Otherwise, staff are likely to be defensive on some issues.
  12. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-neurodevt.pdf
    June 02, 2025 - Behavioral Issues ■ Infants <1500g have an increased risk of behavioral, social, and emotional problems … corrected age is a strong predictor of poor cognitive function, poor academic achievement, and behavioral issues
  13. www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/Culture-Check-UpTool.docx
    June 02, 2025 - assessment and then every 3 to 6 months, or as needed, to promote culture conversations, evaluate cultural issues … Assign someone to complete the Culture Item Discussion Form (next page) to document the issues that surface
  14. www.ahrq.gov/hai/tools/mrsa-prevention/surgery/environmental-cleaning.html
    April 01, 2025 - Spores [List K] CUSP Tool: Staff Safety Assessment (DOCX, 381 KB) Gathers staff insight on safety issues … CUSP Tool: Staff Safety Assessment Sample (DOCX, 316 KB) Gathers staff insight on safety issues and
  15. www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/assemble-slides.html
    July 01, 2023 - Collaborates with others to develop and put into effect a plan that addresses safety issues. … Address issues that require adaptive solutions with measures such as— Implementing an evidence-based … Slide 35: Senior Executive Collaborates To Develop and Implement a Plan Addressing Safety Issues … List identified safety issues in the Safety Issues Worksheet for Senior Executive Partnership or a tracking … Safety Issues Worksheet for Senior Executive Partnership. CEO/Senior Leader Checklist.
  16. www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/improvement-facilitator-guide.pdf
    November 01, 2019 - presentation, participants will be able to—  Recognize how to differentiate technical and adaptive issues … SAY: Errors associated with antibiotic prescribing can be the result of technical or adaptive issues … It identifies issues in the system and aims to prevent them from occurring again. … During multidisciplinary meetings, request input from a diverse group of health care workers about issues … As a group, decide if they are technical and/or adaptive issues and discuss first-order and second-order
  17. www.ahrq.gov/news/events/nac/2020-03-nac/nacmtg032620-minutes.html
    August 01, 2020 - AHRQ could study issues of access and infrastructure. … AHRQ could study issues of quality and safety, as in diagnostic error. … There will be changes and issues regarding the workforce—teamwork, burnout, retraining. Dr. … Masica encouraged AHRQ to study impacts on chronic health issues, especially within populations with … Dahlen encouraged AHRQ to study issues of affordability and access to care. Dr.
  18. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Akins.pdf
    January 01, 2003 - Delphi technique was used for gaining consensus from a group of experts and forecasting significant issues … a problem has not been recorded or reported, which is often the case with patient safety-related issues … Functioning institutional systems for communicating patient safety policies, issues, and activities … The approach to patient safety thus far has been reflective primarily of departmental issues, or has … Issues, possibilities, and challenges for the future.
  19. www.ahrq.gov/cahps/quality-improvement/improvement-guide/5-determining-focus/section5part2.html
    January 01, 2020 - Various operational issues in the practice could contribute to this problem: The physicians may not … Repeatedly asking the question "Why" peels away the layers of issues to uncover the fundamental source … Gather Input From Stakeholders Your analysis of performance issues can benefit from good information … Similarly, give Patient Partners the ability to add issues to the team's agenda. … They may identify issues from the patient perspective that staff do not recognize as problems.
  20. www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/impsteps.html
    January 01, 2017 - Step 11: Pilot All Report/Meeting Strategies in One Unit The team discusses implementation issues with … The facilitator will help the team during the next 3 months to address implementation issues until all … months, the facilitator’s role is to check in to identify obstacles that could occur and to troubleshoot issues … such as turnover of key staff, computer glitches, and implementation issues.

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