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41. Learning From Defects Through Sensemaking: Slide Presentation | Agency for Healthcare Research and Quality
    www.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?

42. Introduction | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/probabilistic-thinking1.html
    September 01, 2022 - Pathway Future Vision for Probabilistic Diagnostic Decisions References Errors that occur

43. Implementation Planning | Agency for Healthcare Research and Quality
    www.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.

44. Job Aid: Process Mapping (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/job-aid-process-mapping.pdf
    June 02, 2025 - 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

45. 130-Ss-Swiss-Cheese-Fg (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/130-ss-swiss-cheese-fg.docx
    April 01, 2025 - pioneering safety researcher, described the “Swiss cheese model” to illustrate how system failures occur … Active failures occur when an “operator” performs an unsafe action that leads to an event. … To learn from these defects, examine the holes that lined up to enable the defect to occur. … Unfortunately, small mistakes in healthcare rarely get a system fix and are therefore often poised to occur … When the holes in the slices of cheese line up, an active failure can occur, leading to a safety event

46. Indwelling Urinary Catheter Maintenance Facilitator Notes (doc file)
    www.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

47. Tool 3. Clinical Care Observation Guide | Agency for Healthcare Research and Quality
    www.ahrq.gov/ncepcr/tools/obesity/obpcp-tool3.html
    May 01, 2014 - When does this counseling occur? How does this counseling occur?

48. Implementation of an Event Reporting and Learning System Leads to Improvements in Patient Safety Culture at UNC Medical Center-Fenton-Wilhelm-Amos (pdf file)
    www.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

49. Understand-Facilitator-Guide (doc file)
    www.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.

50. Supplemental Items for the CAHPS Clinician & Group Adult Survey: Perceived Bias | Agency for Healthcare Research and Quality
    www.ahrq.gov/cahps/surveys-guidance/item-sets/cg/suppl-perceived-bias-cg30-adult.html
    December 01, 2023 - Some items cover events that occur with low frequency in the general population.

51. Chapter 4. Conclusions and Next Steps | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/findings/final-reports/stpra/stpra4.html
    April 01, 2018 - As improvements in the SASD, NIS, and the SEDD databases occur, additional information regarding the … Intervention implementation can occur with or without regulatory oversight; however, the ability to hold … providers accountable for performance in these settings over time is most likely to occur with the establishment … Once the performance steps are identified, education needs to occur, with feedback that addresses the

52. Final Report: Using Risk Models To Improve Safety With Dispensing High-Alert Medications in Community Pharmacies (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/cohen-report.pdf
    January 01, 2024 - The basic events represent 1) exposure rates, or how often certain activities occur; 2) fundamental … Prescribing an incorrect or inappropriate dose of fentanyl patches was estimated to occur in one per … Dosing ranges overlap, so out-of-range dose alerts occur infrequently. … These errors are rarely corrected if data entry verification and patient counseling do not occur. … Patient counseling was estimated to occur with 30% of patients.

53. Appendix A. Exclusion Criteria | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/cusp/clabsi-final-companion/clabsicompapa.html
    January 01, 2013 - To be included, publications had to be full articles, (abstracts were excluded) and CLABSIs had to occur

54. Monitoring for Perinatal Safety: Electronic Fetal Monitoring | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/safe-electronic-tool.html
    July 01, 2023 - determined, and staff should know what resources are available should a sudden change in patient status occur … Recurrent decelerations: occur with ≥ 50% contractions in any 20-min window. … Intermittent decelerations: occur with < 50% contractions in any 20-min window. … Timing : may occur with or without contractions. … Timing : In most cases, the onset, nadir, and recovery occur after the beginning, peak, and ending of

55. Chapter 6. Discussion and Policy Implications | Agency for Healthcare Research and Quality
    www.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 … attempt to both prevent patient safety events from occurring and understand the causes of events that do 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

56. Implementation Guide for the CANDOR Process | Agency for Healthcare Research and Quality
    www.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

57. Healthy Living: Infant Mortality | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/womenhealth/wm-hl.html
    September 01, 2015 - Approximately two-thirds of infant deaths occur in the neonatal period or within 1 month and one-third … occur in the postneonatal period from 1 month to less than 1 year.

58. Concept: Conflict in Teams | Agency for Healthcare Research and Quality
    www.ahrq.gov/teamstepps-program/curriculum/mutual/tools/conflict.html
    July 01, 2023 - Concept: Conflict in Teams It is important to acknowledge that conflict can occur between staff

59. AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/3.html
    December 01, 2017 - Static Week Calculation: Identify all weights that occur in the range of 170-190 days from the most … Static Week Calculation: Identify all weights that occur in the range of 85-95 days from the most … Static Week Calculation: Identify all weights that occur in the range of 25-35 days from the most … The Previous Weight does not need to occur in the week just prior to the most recent week.

60. Sensemakingnotes (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/identify/sensemakingnotes.docx
    June 02, 2025 - . · The Learn from Defects Form, which provides a standardized means to assess where defects occur and … in that the failure mode and effects analysis searches for all possible ways in which an event could occur … These conditions are the mistakes that occur without human error. … failures are problems with physical items, such as equipment and software. · Organizational failures occur … By doing this, teams are able to assign meaning to the system breakdowns that occur on their units.