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1721. NICU Family Information Packet, Appendix B, Growth (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-growth.pdf
      June 02, 2025 - NICU Family Information Packet, Appendix B, Growth Growth General Growth ■ Use growth charts made specifically for premature infants. ■ After infant reaches term corrected gestational age, a standard growth chart may be used. ■ Use corrected postmenstrual age until 2 years of age. ■ Interpretations of catch-u…

1722. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/science-of-safety-facguide.docx
      January 01, 2017 - reporting systems, sentinel events, and claims data are reactive—the unfortunate event has already occurred

1723. Enabling Real-Time Identification of Burnout Risk Among Clinicians in Primary Care Practices (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/about/impact-stories/enabling-real-time.pdf
      January 01, 2023 - Enabling Real-Time Identification of Burnout Risk Among Clinicians in Primary Care Practices Enabling Real-Time Identification of Burnout Risk Among Clinicians in Primary Care Practices AHRQ Impact: Researchers have developed a prediction tool to identify primary care practices at high-risk of clinician burnout…

1724. Re-engineering the Hospital Discharge: An Example of a Multifaceted Process Evaluation (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Anthony.pdf
      January 01, 2005 - means of reducing them, root cause analysis provides indepth insight into errors that have actually occurred—in … technique is used reactively, to probe the reason for a bad outcome or for problems that have already occurred

1725. 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 - AHRQ Safety Program for MRSA Prevention: Targeting SSI Learning From Defects: Applying the “Swiss cheese model” of System Failure Surgical Services For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries Slide Title and Commentary Slide Number and Slide Learning From Defects: Applying the “Swiss C…

1726. Nursing Practice Guide (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/nursing-protocols/nursing-practice-guide.docx
      March 01, 2022 - Nursing Practice Guide Section 9-5 – Decolonization of Non-ICU Patients With Devices Nursing Practice Guide Use this guide to help ensure that all nursing practice processes and leadership support are in place to actively support the decolonization intervention. Engagement and Collaboration CHG Bath Documentation N…

1727. Nursing Practice Guide (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/nursing-protocols/nursing-practice-guide.pdf
      March 01, 2022 - Nursing Practice Guide AHRQ Pub. No. 20(22)-0036 March 2022 Section 9-5 – Decolonization of Non-ICU Patients With Devices Nursing Practice Guide Use this guide to help ensure that all nursing practice processes and leadership support are in place to actively support the decolonization intervention. CHG = c…

1728. FAQs (Staff): Safety and Side Effects: CHG and Mupirocin (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/faqs/faq-safety-chg-mupirocin.docx
      March 01, 2022 - FAQs (Staff): Safety and Side Effects: CHG and Mupirocin Decolonization of Non-ICU Patients With Devices Section 14-6 – Addressing Questions Asked by Staff: Safety and Side Effects of Chlorhexidine and Mupirocin This hospital will be using chlorhexidine gluconate (CHG) and nasal mupirocin to reduce bacteria that c…

1729. Improving Error Reporting in Ambulatory Pediatrics with a Team Approach (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Neuspiel_43.pdf
      March 05, 2008 - pediatric emergency department in Canada, 100 prescribing errors and 39 medication administration errors occurred

1730. 26,000 Close Call Reports: Lessons from the University of Texas Close Call Reporting System (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Simmons_66.pdf
      April 03, 2008 - that explain why employees may not report errors: (1) fear, (2) disagreement over whether an error occurred … Also, because historically reports were submitted only when an actual error had occurred, a “change

1731. Improving Patient Safety in Long-Term Care Facilities, Module 3 (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/ltcmodule3.pdf
      June 01, 2012 - Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Knowing When a Fall Has Occurred … Knowing When a Fall Has Occurred A person can end up on the ground for many reasons.

1732. Module 1: Using the Comprehensive Long-Term Care Safety Modules: Applying Safety Principles: Facilitator Notes | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module1/mod1-facguide.html
      March 01, 2017 - When reckless behavior has occurred, it must be met with remedial or punitive action to decrease or eliminate

1733. Facilitator-Notes (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module1/facilitator-notes.docx
      March 01, 2017 - When reckless behavior has occurred, it must be met with remedial or punitive action to decrease or eliminate

1734. Department of Veterans Affairs Emergency Airway Management Initiative (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Stalhandske_71.pdf
      February 23, 2008 - These claims included some cases that occurred within the operating room. … Our database was unable to differentiate those that occurred due only to emergency airway management.b

1735. PowerPoint Presentation
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/esrd/creating-safety-culture/cultureofsafety_hemodialysis.pptx
      September 03, 2014 - In determining what defect occurred, teams reconstruct the timeline of the event by placing themselves … well as offering help to their peers.     42 Feedback Timely—give soon after the target behavior has occurred … promote a supportive climate, feedback must be:   Timely, and given soon after the target behavior has occurred … Try to view the world as they did when the event occurred.   Why did it happen? Step 1.

1736. On-Time Pressure Ulcer Healing: Facilitator Training Instructor's Guide | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/guide.html
      December 01, 2017 - high risk or had a recent change in risk, would we do things differently to intervene before the event occurred

1737. Tool 3. Clinical Care Observation Guide | Agency for Healthcare Research and Quality
      www.ahrq.gov/ncepcr/tools/obesity/obpcp-tool3.html
      May 01, 2014 - Integrating Primary Care Practices and Community-based Resources to Manage Obesity Tool 3. Clinical Care Observation Guide Previous Page Next Page Table of Contents Integrating Primary Care Practices and Community-based Resources to Manage Obesity Acknowledgements Support Foreword Oregon Rur…

1738. Addressing Questions Asked by Staff: Safety and Side Effects of Chlorhexidine and Mupirocin (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/faqs/faq-safety-chg-mupirocin.pdf
      March 01, 2022 - Addressing Questions Asked by Staff: Safety and Side Effects of Chlorhexidine and Mupirocin Decolonization of Non-ICU Patients With Devices Section 14-6 – Addressing Questions Asked by Staff: Safety and Side Effects of Chlorhexidine and Mupirocin This hospital will be using chlorhexidine gluconate (C…

1739. Introduction | Agency for Healthcare Research and Quality
      www.ahrq.gov/diagnostic-safety/resources/issue-briefs/maternal-mortality-1.html
      September 01, 2021 - The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After Childbirth: State of the Science Introduction Previous Page Next Page Table of Contents The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After Childb…

1740. PowerPoint Presentation
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/esrd/using-checklists/checklistandauditslides.pptx
      September 03, 2014 - Facility A Checklists and monthly process audits were instituted Problem identified: Breaks in process occurred … In determining the defect that occurred, teams reconstruct the timeline of the event by placing themselves … Try to view the world as they did when the event occurred. Why did it happen? Step 1.