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61. Supplemental Items for the CAHPS Health Plan Adult Survey 5.0: Utilization | Agency for Healthcare Research and Quality
    www.ahrq.gov/cahps/surveys-guidance/item-sets/hp/suppl-utilization-hp-adult.html
    December 01, 2018 - Some items cover events that occur with low frequency in the general population.

62. Supplemental Items for the CAHPS Health Plan Child Survey 5.0: Utilization | Agency for Healthcare Research and Quality
    www.ahrq.gov/cahps/surveys-guidance/item-sets/hp/suppl-utilization-hp-child.html
    December 01, 2018 - Some items cover events that occur with low frequency in the general population.

63. 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.

64. 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

65. TeamSTEPPS Implementation Guide (pdf file)
    www.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?

66. TeamSTEPPS Implementation Guide (pdf file)
    www.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?

67. Effect of Chronic Illness Complexity on Evidence-Based Depression Treatment (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/decision/mcc/jordan_grant.pdf
    September 01, 2013 - elderly persons with eight highly prevalent and/or high-cost chronic conditions that commonly co-occur … Considered Depression Eight highly prevalent and/or high cost chronic conditions that commonly co-occur

68. Quick Reference Guide to TeamSTEPPS Action Planning | Agency for Healthcare Research and Quality
    www.ahrq.gov/teamstepps/instructor/reference/quickrefguide.html
    March 01, 2014 - achieved, who will be involved (whose behavior will change), and when and where the change will occur … Write the process steps as they currently occur, identifying who is doing what, when, with what tools … each trainee audience, including who will attend, what will be taught, when and where sessions will occur

69. Job Aid: Process Mapping (pdf file)
    www.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

70. Four Moments of Antibiotic Decision Making | Agency for Healthcare Research and Quality
    www.ahrq.gov/antibiotic-use/acute-care/four-moments/index.html
    November 01, 2019 - This can occur as early as after the first day the patient is on antibiotics; thus, the Moment 3 questions … Moment 4 should occur when the patient’s diagnosis becomes clear.

71. Sizing Up the Culture Exercise Sheet
    www.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

72. 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

73. Leading Teams (pdf file)
    www.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

74. 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.

75. Implementation Guide (pdf file)
    www.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?

76. Understand the Science of Safety for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/perinatal-care/modules/teamwork/understand-sci-fac-guide.html
    May 01, 2017 - Say: Errors occur within the health care setting because health care professionals are human, and humans … 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.

77. Scisafetynotes (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/understand/scisafetynotes.docx
    September 04, 2012 - Slide 4 SAY: Errors occur within the health care setting because people are fallible. … 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.

78. AHRQ Workshop Bolsters New Jersey Patient Safety Act | Agency for Healthcare Research and Quality
    www.ahrq.gov/news/newsroom/case-studies/ockt0504.html
    October 01, 2014 - accountable for their conduct and encouraging honest disclosure and analysis of the errors that inevitably occur … If the desired culture change is to occur, they need to know that their honest sharing of information

79. newbref
    www.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?

80. 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