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  1. www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/learning_pt_narratives_053123-nembhard.pdf
    June 02, 2025 - Learning from Patient Narratives Through Innovative Feedback Reporting Methods Webcast - Impact of the Intervention on Staff Experience Impact of the Intervention on Staff Experience Ingrid Nembhard, PhD Professor of Health Care Management The Wharton School University of Pennsylvania Data Collection: Staff Sur…
  2. www.ahrq.gov/sites/default/files/2024-01/carayon-report.pdf
    January 01, 2024 - sharing of tasks in which one nurse scans and another administers or in which scanning and documenting occur
  3. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Cook.pdf
    January 01, 2004 - Hoas, Katarina Guttmannova Abstract To date, few studies have focused on patient safety issues that occur … case studies, also e-mailed to team members, were based on the kinds of patient safety issues that occur … blameless way for health care providers to present and discuss patient safety issues that could—and did—occur … As a result, decisions about recognizing, reporting, and disclosing errors that occur in rural health
  4. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_opt_briefings.pptx
    December 01, 2017 - They are an opportunity to LISTEN to the wisdom of your frontline providers as defects occur. 2 Safety … By default, they occur at the beginning of a case to ensure every member of the care team is on the same … Huddles occur on an emergent or as-needed basis. … Brief, informal information exchange and feedback sessions Occur after an event or shift Stress learning … Different sections can occur at different times.
  5. www.ahrq.gov/sites/default/files/2024-02/mackenzie-report.pdf
    January 01, 2024 - Final Progress Report: Brief, Risky, High-Benefit Procedures: Best Practice Model Final Progress Report Brief, Risky, High-Benefit Procedures: Best Practice Model Colin F. Mackenzie, MD, Principal Investigator Co-investigators: Yan Xiao, PhD, Grant Bochicchio, MD, Peter Hu, MS, CNE, F. Jacob Seagull, PhD…
  6. www.ahrq.gov/news/newsroom/press-releases/chlorhexidine-bathing.html
    October 01, 2023 - healthcare-associated infections (HAIs) such as MRSA, bloodstream infections, and urinary tract infections occur
  7. www.ahrq.gov/hai/cusp/videos/05h-why-did-happen/index.html
    June 01, 2018 - Why Did It Happen? CUSP Toolkit The CUSP toolkit includes training tools to make care safer by improving the foundation of how your physicians, nurses, and other clinical team members work together. These videos reinforce the material presented in each module of the CUSP toolkit. Apply CUSP To Find Out W…
  8. www.ahrq.gov/sites/default/files/2024-12/danforth-report.pdf
    January 01, 2024 - have primarily focused on inpatient settings; however, an estimated one billion outpatient visits occur … Results: In outpatient settings, care gaps (or deviations from “ideal” care) occur regularly enough
  9. www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-0232-technicalspecs.pdf
    June 02, 2025 - Hypertension Screening for Children Who Are Overweight or Obese: Technical Specifications The percentage of children aged 3 through 17 years with an outpatient care visit and a BMI ≥85th percentile who had a blood pressure percentile documented and classified as normal or abnormal during the measure…
  10. www.ahrq.gov/cahps/surveys-guidance/item-sets/literacy/suppl-interpreter-service-items-hp-survey50-adult.html
    April 01, 2020 - Some items cover events that occur with low frequency in the general population.
  11. www.ahrq.gov/cahps/surveys-guidance/item-sets/literacy/suppl-interpreter-service-items.html
    October 01, 2023 - Additionally, some items cover events that occur with low frequency in the general population.
  12. www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/7.html
    December 01, 2017 - Limited Assistance (LA) Extensive Assistance (EA) Total Dependence (Total) Activity Did Not Occur … No setup (None) Set up only (Set up) One person (1) Two person (2) Activity Did Not Occur
  13. www.ahrq.gov/hai/tools/surgery/modules/implementation/audit-briefing-slides.html
    December 01, 2017 - When did briefing occur? … When did briefing occur? Before patient entered. Before induction. Before incision.
  14. Penicillin Allergy (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/penicillin-allergy-one-pager.pdf
    September 01, 2022 - How soon after taking the antibiotic did the reaction occur? 3.
  15. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Chan.pdf
    January 01, 2004 - Post-fielding Surveillance of a Guideline-based Decision Support System 331 Post-fielding Surveillance of a Guideline- based Decision Support System Albert S. Chan, Susana B. Martins, Robert W. Coleman, Hayden B. Bosworth, Eugene Z. Oddone, Michael G. Shlipak, Samson W. Tu, Mark A. Musen, Brian B. Hoffman, …
  16. www.ahrq.gov/teamstepps-program/curriculum/communication/tools/index.html
    July 01, 2023 - Shift or staff changes: Transitions in care are the times when most communication breakdowns occur. … Where did miscommunication occur in this situation? What are the possible outcomes?
  17. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/c1_pdi_prioritizationworksheetinstructions.pdf
    June 02, 2025 - Ideally, if your data permit, consider only costs that occur after the adverse event occurred.
  18. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheetinstructions.pdf
    June 02, 2025 - Ideally, if your data permit, you would consider only costs that occur after the adverse event occurred
  19. www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/training-tools/slides.html
    October 01, 2020 - Often times spread and sustainability may occur concurrently. … Speak up when a potential break in patient safety protocol may occur or actually occurs.
  20. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Lapane.pdf
    March 09, 2005 - that jeopardize patient safety are common in nursing homes.16 Gurwitz et al.17 estimated that ADEs occur … ADEs occur despite the fact that CMS requires that the drug regimen of each resident be reviewed monthly … this stage of the medication use process are warranted, because of all preventable ADEs, 70 percent occur … at predetermined intervals (e.g., at admission, quarterly, when significant changes in condition occur

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