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41. Slide 1
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/officebasedcare/module11/11_ts_office_impplan.pptx
    January 20, 2006 - When and where will the improvements occur? … When will the training sessions occur and for how long? Where will the sessions occur?

42. Supplemental-Utilization-Hp-Child-2158-13A (doc file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/item-sets/HP/supplemental-utilization-hp-child-2158-13a.docx
    December 08, 2017 - Some items cover events that occur with low frequency in the general population.

43. Supplemental-Utilization-Hp-Adult-2157-13A (doc file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/item-sets/HP/supplemental-utilization-hp-adult-2157-13a.docx
    December 08, 2017 - Some items cover events that occur with low frequency in the general population.

44. Quick Reference Guide to TeamSTEPPS Action Planning | Agency for Healthcare Research and Quality
    www.qualitymeasures.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

45. newbref
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module2/slteamstructure.pptx
    February 02, 2006 - TEAMSTEPPS 05.2 Mod 2 2.0 Page ‹#› Team Structure 2 Page ‹#› Team Structure Teamwork cannot occur … Core team Coordinating team Contingency team Ancillary and support services Where did the breakdowns occur

46. AHRQ Tribal Consultation Policy | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/cpi/about/mission/strategic-plan/tribal-consultation-policy.html
    August 01, 2014 - Policy It is the policy of AHRQ that consultation with Federally-recognized Indian Tribes will occur … Consultation shall occur on a regular basis and may occur on an "as needed" basis as well. … The Agency will also take part in the Department's annual national Tribal budget consultations which occur … Other types of meetings and/or conferences occur in which tribal leaders/representatives and Agency leaders

47. Fallpxtool3A (doc file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallpxtoolkit/fallpxtool3a.docx
    January 28, 2013 - Background: The purpose of this tool is to provide an overview of how fall prevention care processes could occur

48. TeamSTEPPS 2.0: Module 11. Implementation Workshop | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/teamstepps/instructor/fundamentals/module11/igimplement.html
    March 01, 2014 - Write down the process steps as they currently occur and identify who is doing what, when, and with which … intervention: what will be achieved, who will be involved, and when and where the change will occur … Outcome aims focus on changes that occur because your staff carries out the intervention. … Write down the process steps as they currently occur and identify who is doing what, when, with what … When the training sessions will occur and for how long. Where the sessions will occur.

49. Health Care Simulation to Advance Safety: AHRQ Issue Brief (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/publications/files/simulation-brief.pdf
    February 01, 2015 - mistakes safely, and to learn from these mistakes while avoiding patient harms that might otherwise occur … More focused forms of feedback with the guidance of an instructor are likely to occur during a debrief … clinicians’ inquiries, they may evoke a wide range of emotional and behavioral characteristics that occur … Because of the uncertainty, complexity, and rapidly emerging conditions that occur in many health care … Given that unexpected events will occur, there are lessons to be learned regarding their anticipation

50. Supplemental-Providertype-Cgcahps-Adult-2357-10A (doc file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/item-sets/CG/supplemental-providertype-cgcahps-adult-2357-10a.docx
    September 22, 2017 - Some items cover events that occur with low frequency in the general population.

51. The Quick Reference Guide to TeamSTEPPS Action Planning | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/teamstepps/instructor/essentials/implguide3.html
    November 01, 2018 - achieved, who will be involved (whose behavior will change), and when and where the change will occur … during which the problem, challenge or opportunity occurs - write the process steps as they currently occur … trainee audience including who will attend, what will be taught, when and where sessions will occur

52. FileNewTemplate
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/teamstepps/officebasedcare/ts-obc-online-module1.pptx
    March 01, 2010 - Objectives After completing this module, you will be able to: Describe the impact of errors and why they occur … ‹#› After completing this module, you’ll be able to: Describe the impact of errors and why they occur … , and have a shared understanding of how a procedure should happen in order to identify when errors occur … Module 1 Summary In this module you learned to: Describe the impact of errors and why they occur Describe … Module 1: Introduction ‹#› In this module, you learned to: Describe the impact of errors and why they occur

53. Appendix B: Bringing It To Life - Case Study | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/health-literacy/professional-training/lepguide/app-b.html
    September 01, 2020 - It is important to focus on the processes of care that do or do not occur leading to poor communication … patient safety. 64 , 65 While this case may seem extreme, research shows that errors like these occur … patient safety for LEP patients so that they can track these situations and learn from errors that occur

54. Four Moments of Antibiotic Decision Making | Agency for Healthcare Research and Quality
    www.qualitymeasures.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.

55. Supplemental-Medical-Supplies-Hp-Adult-2157-18A (doc file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/item-sets/HP/supplemental-medical-supplies-hp-adult-2157-18a.docx
    December 15, 2017 - Some items cover events that occur with low frequency in the general population.

56. Selected Best Practices and Suggestions for Improvement (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4k_combo_psi14-dehiscence-bestpractices.pdf
    May 20, 2016 - Recommended Practice: Postoperative Wound Assessment • Documentation of the surgical wound should occur … 48 hours after surgery to establish a baseline.1,2,7 • Repeat assessment should occur every shift … Education should occur upon hire, annually, and when this protocol is added to job responsibilities.1

57. Module 2 Instructor Slides (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module2/ts2-0ltc_module2_slides_team.pdf
    June 12, 2017 - teams interact is critical for implementation planning Team Structure • Teamwork cannot occur … Mod 2 LTC 2.0 Page 16 • Ancillary and support services • Where did the breakdowns occur between the

58. Changing-System-Facilitator-Guide (doc file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-facilitator-guide.docx
    June 01, 2021 - Slide 4 Active Failures SAY: Active failures occur because of human error. … Swiss Cheese Model SAY: Let’s return to our “Swiss cheese model” to help visualize where mistakes can occur … As you can see, along the process of an antibiotic prescribing decision, latent failures can occur if … Without these defenses, an “active” or human failure can occur, resulting in a poor outcome. … Change cannot occur if the workforce is not aware and engaged, so share the results from your hard work

59. Selected Best Practices and Suggestions for Improvement (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4b_combo_psi05-foreignbody-bestpractices.pdf
    November 01, 2012 - foreign objects can include perforation of the bowel, sepsis, and even death.1 These complications can occur … o A manual inspection of the incision site should occur, along with inspection of the surrounding surgical … Education should occur upon hire, annually, and when this protocol is added to job responsibilities.2 … performing a failure mode and effects analysis to better understand the process and where breakdowns occur

60. Learn-From-Defects-Facilitator-Guide (doc file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.docx
    May 01, 2017 - The Learn From Defects Form, which provides a standardized means to assess where defects occur and to … These conditions are the mistakes that occur without human error. … Organizational failures occur when decisional elements, such as culture, procedures, and leadership decisions … By doing this, teams are able to assign meaning to the system breakdowns that occur on their L&D unit … defects on the L&D unit, it is important for staff to understand where and how breakdowns in safety occur