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301. Event Reporting and Learning System Leads to Improvements in Patient Safety Culture (Webcast) | Agency for Healthcare Research and Quality
     www.ahrq.gov/sops/events/webinars/unc-improvement-stories/index.html
     February 01, 2024 - Event Reporting and Learning System Leads to Improvements in Patient Safety Culture (Webcast) December 18, 2019 Summary Speakers and Presentation Slides Recording Transcript Summary On Wednesday, December 18, 2019, AHRQ hosted a webcast that highlighted an event reporting initiative from the Uni…

302. How To Avoid the Harms of Antibiotic Overuse | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/education-bundles/urine-culturing/antibiotic-stewardship/part-1-slides.html
     February 01, 2019 - "Extra urine cultures lead to extra antibiotics—and that's not good for anyone." … Slide 10: Avoid Knee-Jerk Antibiotics Remember, unnecessary antibiotic use can lead to— Resident

303. ICU-to-Ward Transitions | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions3.html
     June 01, 2023 - dynamic clinical information, and both cognitive failures and system-based failures, all of which can lead … by ICU or ward physicians. 63 , 64 Ineffective verbal and written handoffs have been estimated to lead

304. System-Focused Event Investigation and Analysis Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4.html
     August 01, 2022 - However, safety science shows that these types of recommendations do not consistently lead to sustained … develop skills necessary for conducting successful event reviews, improve discovery and learning, and lead … Just Culture "People make errors, which lead to accidents. Accidents lead to deaths. … It is essential that employees feel comfortable sharing openly, as that will lead to a more accurate … Very often the answer to a question will lead you to another question.

305. Exhibit 48. Original manual process flow for surgical site infection surveillance | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/ssi/ssiexh48.html
     April 01, 2018 - leading to verification step and an independent documentation step; a suspicious EMR review could also lead

306. Implementation Planning | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps-program/curriculum/implement/activity/plan.html
     February 01, 2024 - A team process is a series of interdependent actions that lead toward a desired endpoint. … following steps: Identify a recurring problem or opportunity for improvement that, if addressed, could lead … Study the process to identify weak points where things could go wrong and lead to a recurrence of the … implementation of interventions will, in turn, prevent the targeted problem from recurring or will lead … Identify risk points where things could go wrong and lead to a recurrence of the problem or challenge

307. 5 Tk2 P3T2-Sample Procedures Phase 3 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/nhguide/5_TK2_P3T2-Sample_Procedures_Phase_3.pdf
     May 01, 2014 - The use of antibiograms can help reduce inappropriate prescribing and lead to fewer clinical failures

308. Implement an Infection Prevention Quality Improvement Project | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/quality/tools/cauti-ltc/infection-prevention.html
     March 01, 2017 - documentation, and small tests of change through the use of the Plan-Do-Study-Act (PDSA) cycle that can lead

309. Generating Health Care Quality Scores That Show Differences | Agency for Healthcare Research and Quality
     www.ahrq.gov/talkingquality/translate/scores/index.html
     March 01, 2016 - Sponsors need to make decisions on these issues carefully, allowing enough lead time for any disagreements

310. Therese Miller, Dr.P.H. | Agency for Healthcare Research and Quality
     www.ahrq.gov/cpi/centers/cepi/miller-bio.html
     September 01, 2023 - In 2008, Tess became the lead of the Prevention/Chronic Care Portfolio, and in 2015 she helped launch

311. Infectionprevchcklst (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/infectionprevchcklst.doc
     June 02, 2025 - Lead efforts to assess the utility and necessity of infection-related technologies, including special

312. Module 2: Communication and Optimal Resolution (CANDOR) Toolkit Module 2: Obtaining Organizational Buy-in and Support
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module2/module2-obtaining-organizational-buy-in-support.pptx
     August 14, 2015 - If a senior leader or the risk management director are not the designated CANDOR Implementation Team Lead … , they can support the CANDOR Implementation Team Lead by helping the team set goals, facilitating progress … The CANDOR Implementation Team Lead is the senior leader who is responsible for organization-wide implementation … The CANDOR Implementation Team and Team Lead can also ask the senior leaders and risk management personnel

313. Implementation of an Event Reporting and Learning System Leads to Improvements in Patient Safety Culture at UNC Medical Center-Mazur (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/3-unc-webcast-mazur.pdf
     June 02, 2025 - activities • Dedicated improvement coaches • Celebrate improvement activities, rewards & recognition, • Lead

314. AHRQ’s Surveys on Patient Safety Culture® Program: An Overview for New Users (Webcast) | Agency for Healthcare Research and Quality
     www.ahrq.gov/sops/events/webinars/sops-primer-011525.html
     February 01, 2025 - Lead Research Analyst User Network for the AHRQ Surveys on Patient Safety Culture (SOPS) Westat SOPS

315. Participating in the 2023 CAHPS® Home and Community-Based Services Survey Database: What You Need to Know - Bakdash (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/2-2023hcbs-survey-webcast-bakdash.pdf
     June 02, 2025 - Agency for Healthcare Research and Quality (AHRQ) AHRQ is: ►A research and science-based agency ►Lead

316. 142-Who-Should-Take-Task-Evc-Monitoring-One-Pager (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/142-who-should-take-task-evc-monitoring-one-pager.docx
     October 01, 2024 - · Clarifies cleaning responsibilities · Shared sense of accountability · Two-way feedback · Can lead

317. 112-Who-Task-Evc-Monitoring-One-Pager (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/112-who-task-evc-monitoring-one-pager.docx
     April 01, 2025 - · Clarifies cleaning responsibilities · Shared sense of accountability · Two-way feedback · Can lead

318. AHRQ-CMS Webcast: "Participating in the 2023 CAHPS® Home and Community-Based Services (HCBS CAHPS) Survey Database: What You Need to Know" | Agency for Healthcare Research and Quality
     www.ahrq.gov/cahps/news-and-events/events/webinar-060624.html
     June 01, 2024 - Consultant, The Lewin Group Falls Church, VA HCBS CAHPS Technical Assistance (PDF, 122 KB)  Joshua Rubin  Lead

319. Why Evaluate a Health Care Quality Reporting Project? | Agency for Healthcare Research and Quality
     www.ahrq.gov/talkingquality/assess/why-evaluate.html
     May 01, 2019 - determine whether your expectations were too ambitious to achieve within the time you allotted; this could lead

320. Executive Summary | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/stpra/stprasumm.html
     April 01, 2013 - ambulatory surgery environment, and examining single-point failures as well as combinations of events that lead … , dependencies and interactions) among the multiple risk points to understand how they collectively lead