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21. Applying a Novel Organization Change Scale in a Multisite Patient Safety Initiative | Agency for Healthcare Research and Quality
    www.talkingquality.ahrq.gov/patient-safety/reports/liability/brock.html
    August 01, 2017 - interventions focused on patient safety generally have not proven effective. 2-4 When success does occur … Disclosure coaches strengthen clinician confidence and allow disclosure to occur in a timely fashion. … Our organizations’ leaders and stakeholders hold a shared vision that organizational change needs to occur … organization’s leaders and stakeholders hold a shared vision of what organizational change needs to occur … organization’s leaders and stakeholders hold a shared vision of how organizational change needs to occur

22. Chapter 2: Five Key Recommendations To Improve Patient Safety for LEP Patients | Agency for Healthcare Research and Quality
    www.talkingquality.ahrq.gov/health-literacy/professional-training/lepguide/chapter2.html
    September 01, 2020 - engage in a systematic approach to better identify and prevent medical errors and adverse events that occur … Medical Errors Among LEP Patients Background To accurately identify and analyze medical errors that occur … need of improvement to ensure that staff are empowered and can identify and report medical errors that occur … not receive training on what constitutes an error or a near miss, or on how to report these when they occur … Hospitals rarely analyze events that occur among culturally diverse and LEP patients.

23. Understand the Science of Safety for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
    www.talkingquality.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/understand-sci-fac-guide.html
    July 01, 2023 - 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.

24. Surge in Drug Shortages Occurred in Wake of Pandemic, Study Finds | Agency for Healthcare Research and Quality
    www.talkingquality.ahrq.gov/news/newsletters/e-newsletter/908.html
    April 01, 2024 - 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 …

25. Slide 1
    www.talkingquality.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?

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

27. AHRQ Tribal Consultation Policy | Agency for Healthcare Research and Quality
    www.talkingquality.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

28. Health Care Simulation to Advance Safety: AHRQ Issue Brief (pdf file)
    www.talkingquality.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

29. The Quick Reference Guide to TeamSTEPPS Action Planning | Agency for Healthcare Research and Quality
    www.talkingquality.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

30. FileNewTemplate
    www.talkingquality.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

31. Appendix B: Bringing It To Life - Case Study | Agency for Healthcare Research and Quality
    www.talkingquality.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

32. Four Moments of Antibiotic Decision Making | Agency for Healthcare Research and Quality
    www.talkingquality.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.

33. Selected Best Practices and Suggestions for Improvement (pdf file)
    www.talkingquality.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

34. Module 2 Instructor Slides (pdf file)
    www.talkingquality.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

35. Selected Best Practices and Suggestions for Improvement (pdf file)
    www.talkingquality.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

36. Learn-From-Defects-Facilitator-Guide (doc file)
    www.talkingquality.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

37. TeamSTEPPS Implementation Guide | Agency for Healthcare Research and Quality
    www.talkingquality.ahrq.gov/teamstepps/instructor/essentials/implguide.html
    November 01, 2018 - Key Actions: Multiple actions occur during Phase I to assess organizational readiness for a TeamSTEPPS … Where will it occur? What do we hope to achieve with a TeamSTEPPS Intervention? … Key Actions: Three key actions occur during Phase II — writing a TeamSTEPPS Action Plan, conducting … TeamSTEPPS Action Plan written during Phase II provides the "how-to" guidelines for the key actions that occur … targeted problem or opportunity for improvement occurs – write down the process steps as they currently occur

38. Neonatal Intensive Care: All Condition Readmissions with Gestational Age Reported: Technical Specifications (pdf file)
    www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0207-technical-specifications.pdf
    January 30, 2020 - focus on the overall quality of care of the NICU, as some of the variation in readmission rates may occur

39. Pressure Ulcer Prevention Toolkit (doc file)
    www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module4/putoolkit_module4_tools.docx
    January 01, 1995 - Friction may occur when moving a person up in bed. 43. … For persons who have incontinence, skin cleaning should occur at the time of soiling and at routine intervals … Friction may occur when moving a person up in bed. True 43. … For persons who have incontinence, skin cleaning should occur at the time of soiling and at routine intervals

40. FileNewTemplate
    www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/teamstepps/officebasedcare/ts-obc-online-module11.pptx
    March 07, 2019 - So, look at those things that occur frequently. … When and where will the improvements occur? … The outcome aims should focus on changes that occur because your staff carries out the interventions … Write down the process steps as they currently occur, and identify who’s doing what, when, with what … When will the training sessions occur and for how long? Where will the sessions occur?