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61. Module 4: Teamwork and Communication: Facilitator Notes | Agency for Healthcare Research and Quality
    www.cahps.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

62. AHRQ Papers on Diagnostic Safety Topics | Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/patient-safety/reports/dxsafety-issuebriefs.html
    January 01, 2024 - Resources AHRQ Papers on Diagnostic Safety Topics Diagnostic errors occur

63. AHRQ Quality and Safety Review System (QSRS) | Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/patient-safety/quality-measures/qsrs/index.html
    September 01, 2022 - Medicine report, To Err Is Human , revealed more than 15 years ago the extent of medical errors that occur

64. Silence A Commentary | Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/patient-safety/reports/liability/silence.html
    August 01, 2017 - Yet, when harm does occur, and honest and transparent conversations are not conducted, you harm us again

65. Suppl-Access Items Cg-Cahps-Adult-Survey 2357-1A (doc file)
    www.cahps.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/cg/instructions/suppl-access_items_cg-cahps-adult-survey_2357-1a.docx
    March 11, 2016 - Some items cover events that occur with low frequency in the general population.

66. Hypertension Screening for Children Who Are Overweight or Obese: Technical Specifications (pdf file)
    www.cahps.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-0232-technicalspecs.pdf
    February 04, 2020 - 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 measurem…

67. TeamSTEPPS Rapid Response Systems Module | Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/teamstepps/rrs/rrs_slides/rrsslides.html
    July 01, 2018 - Identify Your RRS Structure RRS Execution Detection Detection: STEP Assessment Where can Detection occur … Return to Top Where can Detection occur? … Detection can occur from a variety of sources or concerns Image: Activator penguin holding oversize … Return to Top Evaluation: Debriefs Debriefs occur right after the event and are conducted by the

68. 6 Tk1 T1-Talking With Residents Checklist Version Final (pdf file)
    www.cahps.ahrq.gov/sites/default/files/wysiwyg/nhguide/6_TK1_T1-Talking_with_Residents_checklist_version_Final.pdf
    October 01, 2016 - There are five potential health problems that occur as a result of taking an antibiotic. 1.

69. AHRQ's Safety Program for Nursing Homes: On-Time Falls Prevention Training (pdf file)
    www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallpxreports-ig.pdf
    November 09, 2017 - Falls that occur within 1-7 days of the report date will be noted in high risk based on change of condition … Falls that occur within 1-7 days of the report date will be noted in high risk based on change of condition … Likewise, if multiple minor injuries occur, they will only be counted as one and if multiple major … injuries occur, they will only be counted as one. … Regardless of whether the report is monthly or quarterly, a room change must occur within 30 days

70. Hypertension Screening for Children Who Are Overweight or Obese: Table 2 (pdf file)
    www.cahps.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-0232-table2.pdf
    January 01, 2011 - Although death and cardiovascular disability don’t occur in children with hypertension, intermediate

71. Asthma 1 Measure Calculation Steps (pdf file)
    www.cahps.ahrq.gov/sites/default/files/wysiwyg/pqmp/toolkits/flow-diagrams.pdf
    March 11, 2021 - This means, for a given member-month, a comorbidity may occur in the future (but only within the same

72. Tips and Suggestions for Enhancing Organizational Readiness | Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/teamstepps/readiness/abouttips.html
    April 01, 2016 - Skip to main content An official website of the Department of Health and Human Services Careers Contact Us Español FAQs Search all AHRQ sites Search small Search Menu …

73. Federal Interagency Workgroup on Improving Diagnostic Safety--March Meeting Summary (pdf file)
    www.cahps.ahrq.gov/sites/default/files/wysiwyg/topics/DxSafety-March2019-MeetingNotes.pdf
    March 08, 2019 - Federal Interagency Workgroup on Improving Diagnostic Safety--March Meeting Summary Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Health Care March Meeting Summary Workgroup Goal: Established in response to Senate Report 115-150. The Senate Committee on Appropriations requested t…

74. AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Under the Science of Safety
    www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-science-safety.pptx
    May 01, 2017 - AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Under the Science of Safety AHRQ Safety Program for Perinatal Care Understand the Science of Safety for Perinatal Safety AHRQ Publication No. 17-0003-4-EF May 2017 1 Learning Objectives 2 AHRQ Safety Program for Perinatal Care Science of S…

75. Suppl-Access Items Cg-Cahps-Child-Survey 2358-1A (doc file)
    www.cahps.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/cg/instructions/suppl-access_items_cg-cahps-child-survey_2358-1a.docx
    March 11, 2016 - Some items cover events that occur with low frequency in the general population.

76. Strategies for Improving CAHPS Clinician & Group (CG-CAHPS) Survey Scores (pdf file)
    www.cahps.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/20160315/debra-rosen-slides.pdf
    March 15, 2016 - agencies)  Focus priorities at the site or organizational level  Significant change/efforts must occur

77. Re-engineering the Hospital Discharge: An Example of a Multifaceted Process Evaluation (pdf file)
    www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Anthony.pdf
    January 01, 2005 - Forster, et al.4 provide data demonstrating that many adverse events occur at the time of hospital discharge … Errors occur when latent conditions or system failures occur that are the consequences of failures in … Many adverse effects occur during the peridischarge period, and many could be prevented with relatively … industries as a proactive, systematic way of examining processes for possible ways in which failure can occur … • Patient education must occur throughout the hospitalization, not only at the time of discharge

78. Prioritization Worksheet (pdf file)
    www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheetinstructions.pdf
    June 05, 2016 - Ideally, if your data permit, you would consider only costs that occur after the adverse event occurred

79. Workflow (pdf file)
    www.cahps.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/workflow-analysis-qi.pdf
    February 01, 2005 - • Encourage open dialogue • Record your system workflow as it truly occurs, not how it should occur

80. Creating a Culture of Patient Safety through Innovative Hospital Design (pdf file)
    www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Reiling.pdf
    January 01, 2004 - Churchill According to the Institute of Medicine (IOM),1 tens—if not hundreds—of thousands, of errors occur … The majority of errors that occur are considered “near misses”—errors that could have caused harm to … The IOM reported that the probability of a hospital preventable medical death will occur in the range … of 3 to 6 per 1,000 admissions and that an adverse event will occur in the range of 3 to 4 per every … In these types of activities, errors known as slips or mistakes (lapses) can occur for multiple reasons