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101. Sensemakingnotes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/identify/sensemakingnotes.docx
     June 02, 2025 - Slide 1 SAY: Some of the tools that will help CUSP teams identify and learn from defects include: … , and bringing safety issues to the attention of the senior executive partnership to address. · The Learn … One Sensemaking tool that will help CUSP teams identify and learn from defects is the Discovery Form, … Sensemaking is a way for a unit to learn from and prevent mistakes. … Further guidance to complete this exercise can be found using the CUSP Learn from Defects Form.

102. The SHARE Approach: A Flexible Training Program for Shared Decision Making (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sdm/share-approach/share-fact-sheet.pdf
     October 01, 2024 - Benefits to your organization and clinicians • Learn shared decision-making and communication skills … • Learn how to find and use evidence-based patient decision aids to support shared decision making … Visit www.ahrq.gov/sdm/share-approach/index.html to learn how to implement the SHARE Approach at your

103. State at a Glance: New Mexico | Agency for Healthcare Research and Quality
     www.ahrq.gov/policymakers/chipra/demoeval/demostates/nm.html
     March 01, 2019 - State at a Glance: New Mexico Learn more about the CHIPRA quality demonstration projects being … Learn more about New Mexico’s CHIPRA quality demonstration projects on this page: Overview New … Mexico's Objectives Evaluation Questions Additional Resources Learn More   Overview New … Top of Page   Learn More This information is current as of February 2014, slightly more than 4 years … To learn more about the projects that New Mexico is implementing under the CHIPRA Quality Demonstration

104. Overview of the Comprehensive Unit-based Safety Program for Application to Mechanically Ventilated Patients: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/modules/cusp/overview-cuspmvp-slides.html
     February 01, 2017 - Designed to improve safety culture and help users learn from mistakes. … Identify defects: Learn from staff reports of safety concerns, event reports, etc. … Slide 9: Steps of CUSP Learn from defects: What happened? Why did it happen? … Learn from defects. … Learn from defects.

105. Learn About the Comprehensive Unit-based Safety Program for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-about-cusp-fac-guide.html
     July 01, 2023 - Learn About the Comprehensive Unit-based Safety Program for Perinatal Safety: Facilitator Guide … AHRQ Safety Program for Perinatal Care Slide 1: Learn About the Comprehensive Unit-based Safety … Slide 6: SPPC CUSP Modules Say: In addition to this Learn About CUSP module, the first program … Sensemaking and Learn From Defects. Implement Teamwork and Communication.

106. State at a Glance: South Carolina | Agency for Healthcare Research and Quality
     www.ahrq.gov/policymakers/chipra/demoeval/demostates/sc.html
     March 01, 2019 - State at a Glance: South Carolina Learn more about the CHIPRA quality demonstration projects … Practice-Reported Medical Homeness and Health Care Utilization Among Publicly Insured Children Learn … demonstration projects on this page: Overview South Carolina's Objectives Evaluation Questions Learn … Top of Page   Learn More This information is current as of February 2014, slightly more than 4 years … To learn more about the projects being implemented in South Carolina under the CHIPRA Quality Demonstration

107. Reducing Disparities in the Primary Prevention of Cardiovascular Disease (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/decision/research-centers/persell_cvd_disparities.pdf
     June 02, 2025 - prevention-for-all.org/ Reducing Disparities in Primary Prevention of Cardiovascular Disease What Did We Learn … Where to Learn More Articles describing the findings from this study are in production. … Reducing Disparities in the Primary Prevention of Cardiovascular Disease Big Questions What Did We Learn … Where to Learn More The Center for Advancing Equity in Clinical Preventive Services Center Location

108. CLABSI and CAUTI Learning Tools | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/clabsi-cauti-icu/implement/learning-tools.html
     February 01, 2025 - CLABSI Event Report Tool ( Word , 274 KB) CAUTI Event Report Tool ( Word , 270 KB) CLABSI Learn From … Defects Tool ( PDF , 412 KB; Word , 271 KB) CAUTI Learn From Defects Tool ( PDF , 419 KB; Word , 267

109. State at a Glance: Florida | Agency for Healthcare Research and Quality
     www.ahrq.gov/policymakers/chipra/demoeval/demostates/fl.html
     March 01, 2019 - State at a Glance: Florida Learn more about the CHIPRA quality demonstration projects being implemented … Nine States’ Use of Collaboratives to Improve Children’s Health Care Quality in Medicaid and CHIP Learn … quality demonstration projects on this page: Overview Florida's Objectives Evaluation Questions Learn … Top of Page Learn More This information is current as of February 2014, slightly more than 4 … To learn more about the projects that Florida is implementing under the CHIPRA Quality Demonstration

110. Tip 5. Make a Health Care Quality Report Culturally Appropriate | Agency for Healthcare Research and Quality
     www.ahrq.gov/talkingquality/resources/writing/tip5.html
     September 01, 2019 - Learn more about your audience’s knowledge, attitudes, and beliefs . … Learn more about testing your written materials with readers: Tip 7. … Learn more about using feedback from readers to make written material more effective and culturally appropriate

111. Leveraging Existing Assessments of Risk Now (LEARN) Safety Analysis: A Method for Extending Patient Safety Learning (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-woods_79.pdf
     May 30, 2008 - Leveraging Existing Assessments of Risk Now (LEARN) Safety Analysis: A Method for Extending Patient Safety … Learning Leveraging Existing Assessments of Risk Now (LEARN) Safety Analysis: A Method for Extending … This article describes how the Leveraging Existing Assessments of Risk Now (LEARN) Safety Analysis method … To be clear, this LEARN Safety Analysis method is not intended to provide an epidemiology of types of … The LEARN Safety Analysis method is more akin to a meta-analysis of risk assessment data to glean and

112. Staff Safety Assessment
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/identify/sensemaking.pptx
     January 01, 2006 - Sensemaking Tools Staff Safety Assessment Discovery Form Safety Issues Worksheet Root Cause Analysis Learn … Effects Analysis -Probabilistic Risk Assessment Tools to examine defects or failures Learn … from Defects Form Causal Tree Worksheet Coding defects or failures Learn From Defects Form Eindhoven … CUSP Tools To Learn From Defects 20 21 Learning From Defects: Four Questions 1. … 25 Sensemaking Tools To Learn From Defects 26 Causal Coding: Eindhoven Model6 20 separate event

113. State at a Glance: Oregon | Agency for Healthcare Research and Quality
     www.ahrq.gov/policymakers/chipra/demoeval/demostates/or.html
     March 01, 2019 - State at a Glance: Oregon Learn more about the CHIPRA quality demonstration projects being implemented … Learn more about Oregon’s CHIPRA quality demonstration projects on this page: Overview Oregon's … Objectives Evaluation Questions Learn More Overview As one of the 10 grantees, Oregon … Top of Page   Learn More This information is current as of February 2014, slightly more than … To learn more about projects that are being implemented in Oregon under the CHIPRA Quality Demonstration

114. Long COVID Email Updates | Agency for Healthcare Research and Quality
     www.ahrq.gov/coronavirus/long-covid/email.html
     June 01, 2024 - Learn more about AHRQ’s Long COVID grantees, funding opportunities, reports, and other AHRQ activities

115. State at a Glance: West Virginia | Agency for Healthcare Research and Quality
     www.ahrq.gov/policymakers/chipra/demoeval/demostates/wv.html
     March 01, 2019 - State at a Glance: West Virginia Learn more about the CHIPRA quality demonstration projects being … Nine States’ Use of Collaboratives to Improve Children’s Health Care Quality in Medicaid and CHIP Learn … demonstration projects on this page: Overview West Virginia's Objectives Evaluation Questions Learn … Top of Page   Learn More This information is current as of February 2014, slightly more than 4 years … To learn more about the projects being implemented in West Virginia under the CHIPRA Quality Demonstration

116. CAUTI Prevention Implementation in a Community Hospital
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/assess-adapt-060314.pptx
     March 01, 2009 - Program (CUSP) Educate staff on science of safety Identify defects Assign executive to adopt unit Learn … Comprehensive Unit-based Safety Program An intervention to improve teamwork and safety culture and learn … Error (Reason, 1990) Three Principles of Safe Design 18 Standardize Create independent checks Learn … 23 Learn When Things Go Wrong 24 First vs. … when others do Create clear goals, ask questions early Standardize, create independent checks, and learn

117. Project Report - Lean Sigma (ppt file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/contentcalls/framework-slides/CUSP-A-Framework-for-Success-Mar-7-2012-508.ppt
     January 01, 2012 - Create line cart Create independent checks: Create BSI checklist Empower nurses to stop takeoff Learn … How Do We Know We Learn From Mistakes? … Safety Program Educate staff on science of safety Identify defects Assign executive to adopt unit Learn … 66% 95% How often did we learn from mistakes?* 100s 100s Have we created a safe culture? … Steps of CUSP Educate staff on science of safety Identify defects Assign executive to adopt unit Learn

118. State at a Glance: Alaska | Agency for Healthcare Research and Quality
     www.ahrq.gov/policymakers/chipra/demoeval/demostates/ak.html
     March 01, 2019 - State at a Glance: Alaska Learn more about the CHIPRA quality demonstration projects being implemented … Learn more about Alaska’s CHIPRA quality demonstration projects on this page: Overview Alaska's … Objectives Evaluation Questions Learn More     Overview Alaska is working with Oregon … Top of Page   Learn More This information is current as of February 2014, 4 years after the grant … To learn more about the projects that Alaska is implementing under the CHIPRA Quality Demonstration Grant

119. Measure Dx: A Resource To Identify, Analyze, and Learn From Diagnostic Safety Events | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/tools/measure-dx.html
     March 01, 2024 - Measure Dx: A Resource To Identify, Analyze, and Learn From Diagnostic Safety Events … Case examples illustrate how organizations have used each strategy to learn about diagnostic safety in

120. Improving Rates of Repeat Colorectal Cancer Screening in Community Health Centers (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/decision/research-centers/baker_crc_screening.pdf
     January 01, 2014 - In particular, the study aimed to learn about the effectiveness of a program to maximize the number … Improving Rates of Repeat Colorectal Cancer Screening in Community Health Centers What Did We Learn … Where to Learn More Baker DW, Brown T, Buchanan DR, et al. … Screening in Community Health Centers What Was Done in the Intervention Big Questions What Did We Learn … Where to Learn More The Center for Advancing Equity in Clinical Preventive Services Center Location