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21. The Ten Steps of Action Planning  | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/teamstepps/instructor/essentials/implguide1.html
    November 01, 2018 - Outcome aims focus on changes that occur because your staff carries out the intervention. … Rates are calculated by dividing the number of events that did occur by the total number of opportunities … for the event to occur. … This measure is particularly useful for clinical processes that should occur within a limited period … When the training sessions will occur and for how long. Where the sessions will occur.

22. Implementation Planning | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/teamstepps-program/curriculum/implement/activity/plan.html
    February 01, 2024 - Write down the process steps as they currently occur and identify who is doing what, when, and with which … what you hope will be achieved, who will be involved, and when and where the improvements will occur … Outcome aims focus on changes that occur because your staff carry out the intervention. … Write down the process steps as they currently occur and identify who is doing what, when, and with … When the training sessions will occur and for how long. Where the sessions will occur.

23. Equipment and Supplies | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/research/shuttered/toolkitchecklist/surgetkit3.html
    July 01, 2018 - Timeframe: The operations activities listed below will occur between opening day and until the facility … The steps listed below must occur for this process to be successful. … will be transported within the first few days, but continued patient transport to the facility might occur … Also, termination of on-going contracts or arrangements must occur. … determined that the surge facility is no longer needed, all patient transport out of the facility should occur

24. Learning From Defects Through Sensemaking: Slide Presentation | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-slides.html
    December 01, 2017 - List contributing factors that make defects in care more likely to occur. … The “5 Why’s” technique can help: Why 1: Why did this contributing factor occur? … Why 2: Why did the answer to “Why 1” occur? Why 3: Why did the answer to “Why 2” occur? … Why 4: Why did the answer to “Why 3” occur? Why 5: Why did the answer to “Why 4” occur? … Does it occur rarely or have a high likelihood of reoccurring?

25. Leading Teams (Instructor Guide) (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module4/ts2-0ltc_module4_ig_lead.pdf
    May 10, 2017 - Did the items on this checklist occur? If not, what was not done? … When would the briefing occur? … In addition, information updates within the team should occur as often as necessary. … Did the items on this checklist occur? If not, what was not done? … When would the briefing occur? Who would be expected to attend? 1.

26. Chapter 6. Discussion and Policy Implications | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/chapter6.html
    August 01, 2022 - indicated that the consumer perspective may be particularly important for patient safety events that occur … system features (often substantially removed from the consumer) that enabled a patient safety event to occur … This may particularly apply to patient safety events that occur in outpatient settings, where there is … Decisions regarding system functions/activities that occur at the "system hub" versus those that occur … However, this type of collaboration cannot occur unless facility-based reporting systems are in operation

27. Indwelling Urinary Catheter Maintenance Facilitator Notes (doc file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-catheter-maintenance-notes.docx
    April 01, 2022 - In addition to proper insertion, contamination can occur due to breaks in the collection system. … associated with maintaining a sterile, closed system at all times and recommends that if breaks or leakage occur … It is important to consider replacing the indwelling urinary catheter if breaks or leakage occur. … If breaks in the aseptic technique, disconnection, or leakage occur, replace the catheter using aseptic

28. Job Aid: Process Mapping (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/job-aid-process-mapping.pdf
    May 17, 2021 - specific actions of different individuals (or departments) in the process and the places where handoffs occur … Remind participants to use appropriate symbols, stack actions that occur at same time, and reevaluate

29. TeamSTEPPS Implementation Guide (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/essentials/implguide.pdf
    March 01, 2006 - Where will it occur?  What do we hope to achieve with a TeamSTEPPS Intervention? … for the event to occur. … When does the “problem” occur? … When will the improvement occur? Within what timeframe? … When will the improvement occur? Within what timeframe?

30. TeamSTEPPS Implementation Guide (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/essentials/implguide_0.pdf
    March 01, 2006 - Where will it occur?  What do we hope to achieve with a TeamSTEPPS Intervention? … for the event to occur. … When does the “problem” occur? … When will the improvement occur? Within what timeframe? … When will the improvement occur? Within what timeframe?

31. Implementation Guide for the CANDOR Process | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/impguide.html
    August 01, 2022 - For example, more than 1.5 million preventable infections occur annually among inpatients. … While these two processes occur at the same time during the CANDOR process, they have been numbered for … While an initial disclosure conversation will occur within 60 minutes after the CANDOR event occurs, … a full disclosure will typically not occur until after the Event Investigation and Analysis has been … Figure 2: CANDOR Implementation Phases Phase I: Assessments Phase I activities should occur during

32. Sizing Up the Culture Exercise Sheet
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module4/ts2-0ltc_module4_slides_lead.pptx
    February 02, 2006 - of nursing that the home develop a more effective plan for responding to resident emergencies that occur … In addition, because these events do not occur within a unit, but involve residents and staff from multiple … the Team’s Performance: Debrief Process Improvement Short information exchange and feedback sessions Occur

33. Leading Teams (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module4/ts2-0ltc_module4_slides_lead.pdf
    June 12, 2017 - nursing that the home develop a more effective plan for responding to resident emergencies that occur … In addition, because these events do not occur within a unit, but involve residents and staff from … s Performance: Debrief Process Improvement � Short information exchange and feedback sessions � Occur

34. Implementation of an Event Reporting and Learning System Leads to Improvements in Patient Safety Culture at UNC Medical Center-Fenton-Wilhelm-Amos (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/4-unc-webcast-fenton-wilhelm-amos.pdf
    August 15, 2019 - increased length of stay nor increased level of care) Probability Categories: Frequent (likely to occur … immediately or within a short period of time), Occasional (probably will occur), Uncommon (possible … to occur), Remote (unlikely to occur) How the SAC Matrix Works: When a severity category is paired

35. Understand-Facilitator-Guide (doc file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-facilitator-guide.docx
    May 01, 2017 - Slide 3 SAY: Errors occur within the health care setting because health care professionals are human … Providers, executives, and managers need to understand why errors occur. … Errors occur because medicine is still treated as an art, not a science. … In analyzing how errors occur, frontline providers must recognize the scientific nature of medicine. … Errors also occur because systems frequently do not catch mistakes before they reach the patient.

36. Implementation Guide (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module11/ts2-0ltc_module11_impguide.pdf
    June 22, 2017 - ■ When and where will the improvements occur? … When will the training sessions occur and for how long? Where will the sessions occur?

37. newbref
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module11/m11impguide.pptx
    February 03, 2006 - When and where will the improvements occur? … When will the training sessions occur and for how long? Where will the sessions occur?

38. Human Factors in Surgery: Shifting the Paradigm on Patient Safety | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/funding/grantee-profiles/grtprofile-catchpole.html
    December 01, 2022 - 4,000 annual “never events”—shocking medical errors, such as wrong-site surgery, that should never occur … Delivery  , focuses on reducing the 200,000 to 20 million anesthesia-related medication injuries that occur … Factors and Systems Integration in High Technology Surgery , explores the root causes of errors that occur

39. Patient, Family Member, and Clinician Perceptions of Disclosure of Adverse Events in Labor and Delivery | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/reports/liability/baker.html
    August 01, 2017 - families in the care team and how to communicate with patients about the risks and mistakes that can occur … kinds of information should be disclosed regarding each event and explore how communication should occur … Second, we wanted to ascertain how patient and family and provider communication should occur to mitigate … Last, we interviewed 12 clinicians about the common failures that can occur leading to each event. … The highest level of agreement was for those failures that could occur during the Delivery phase for

40. 6 Tk1 T2-Talking With Residents Family Members Checklist Version Final (doc file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/nhguide/6_TK1_T2-Talking_with_Residents_Family_Members_checklist_version_Final.docx
    October 01, 2016 - There are five potential health problems that occur as a result of taking an antibiotic. 1. … Although we cannot be certain that any of these problems will occur, it is important that you and your