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  1. pbrn.ahrq.gov/priority-populations/observances/hispanic-heritage/index.html
    October 01, 2021 - built an automated language translation tool to allow clinical evaluations of recorded interviews to occur
  2. pbrn.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/communication-facilitator-guide.docx
    June 01, 2021 - This can occur after someone has had antibiotics and can be devastating in nursing home residents. … 13 Case 3: Communication SAY: Let’s walk through a final case of communication errors that can occur … The nurse does not feel comfortable with this plan and knows that serious side effects can occur on antibiotics … Slide 16 Case 3 — DESC Script SAY: Conflict can occur in teams, and it is important to know how … to handle such situations when they occur.
  3. pbrn.ahrq.gov/cpi/about/otherwebsites/qsrs.ahrq.gov/index.html
    March 01, 2021 - SHARE: More topics in this section About About AHRQ AHRQ's 35th Anniversary Profile Mission and Budget AHRQ’s Core Competencies Health Equity National Advisory Council for Healthcare Research and Quality National Actio…
  4. pbrn.ahrq.gov/hai/cusp/modules/patient-family-engagement/notes.html
    September 01, 2013 - Introduction to Adverse Events Say: Adverse events occur when a patient is harmed as a result of … Rarely does an adverse event occur as a result of intent.
  5. pbrn.ahrq.gov/hai/pfp/2015-interim.html
    December 01, 2016 - SHARE: More topics in this section Healthcare-Associated Infections Program Combating Antibiotic-Resistant Bacteria About the CUSP Method Decolonization – Universal and Targeted Tools National Scorecard on Rates of Hospi…
  6. pbrn.ahrq.gov/patient-safety/news-events/psaw-2022/index.html
    July 01, 2022 - Thomas, M.D., M.P.H., " Understanding Where, Why, and How Diagnostic Errors Occur " AHRQ PSNet Primer
  7. pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module4/module4_pu-implementation_slides.pptx
    November 20, 2014 - Unit staff tell the Wound Care Team about high-risk patients or if skin problems occur. … 19 Practice Insight Staff Turnover 20 Communication Patterns Good communication needs to occur
  8. pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/mod5-disclosure-checklist.pdf
    April 01, 2016 - tool: Use Part I of the checklist to prepare for the initial disclosure conversation, which should occur
  9. pbrn.ahrq.gov/news/blog/ahrqviews/eliminate-diagnostic-errors.html
    August 01, 2022 - An estimated 250,000 diagnostic errors occur annually in U.S. hospitals.
  10. pbrn.ahrq.gov/sites/default/files/wysiwyg/teamstepps/instructor/onlinecourse/tsonlinemodule11.pptx
    November 02, 2018 - When and where the improvements will occur? … Outcome aims focus on changes that occur because your staff carries out the intervention. … When will the training sessions occur and for how long? Where will the sessions occur? … When will training occur and how long will the sessions last? … When will training occur and how long will the sessions last?
  11. pbrn.ahrq.gov/teamstepps-program/curriculum/communication/tools/checkback.html
    July 01, 2023 - patient harm are often caused by a provider overlooking messages alerting them to a test result or occur
  12. pbrn.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module4/mod4-facguide.html
    March 01, 2017 - Slide 17: For Information Transfer – Handoffs Say: Handoffs occur during a change in assignment … A handoff may occur when a resident is first welcomed to the nursing home from the hospital or during … another staff member, even for a short timespan such as a lunch break, a structured communication should occur
  13. pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy2/Strat2_Tool_1_Be_Partner_508.docx
    February 10, 2011 - Nurse shift changes occur when nurses who are going off duty share information about you with nurses
  14. pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/decision/research-centers/new_model_thinking.pdf
    February 01, 2014 - University of North Carolina, Chapel Hill, is focused on reducing unintended harms to patients that occur
  15. pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module5/module5_tools.docx
    August 03, 2017 - Ensure timescales for assessing and preventing falls are tailored to when falls are most likely to occur … Observations at the bedside should occur at the time of day when most patients who are well enough would
  16. pbrn.ahrq.gov/teamstepps-program/curriculum/communication/overview/index.html
    June 01, 2023 - This step is particularly crucial for handoffs that occur electronically (e-handoffs).
  17. pbrn.ahrq.gov/hai/tools/surgery/index.html
    December 01, 2017 - address respectively adaptive and technical work, which are both critical elements for improvement to occur
  18. pbrn.ahrq.gov/teamstepps/readiness/abouttips.html
    April 01, 2016 - SHARE: More topics in this section TeamSTEPPS® About TeamSTEPPS® Readiness Assessment Curriculum Materials TeamSTEPPS® 2.0 Online Master Trainer Course Research/Evidence Base TeamSTEPPS® Webinars Tips and…
  19. pbrn.ahrq.gov/research/findings/making-healthcare-safer/index.html
    July 01, 2023 - SHARE: More topics in this section Research Publications & Products Research Findings & Reports Grantee Final Reports: Patient Safety Evidence-based Practice Center Reports Fact Sheets National Healthcare Quality & Disparities Rep…
  20. pbrn.ahrq.gov/teamstepps/instructor/fundamentals/module3/igcommunication.html
    March 01, 2019 - which information must be communicated, a leader must be clearly designated, and mutual support must occur … Discuss findings with the group regarding root cause analyses from events that occur in your organization … Shift change—Transitions in care are the most significant time when communication breakdowns occur. … Discussion: Where might miscommunication occur in this situation?

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