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2301. 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

2302. 055-Guide-Nursing-Practice (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/055-guide-nursing-practice.docx
      October 01, 2024 - AHRQ Safety Program for MRSA Prevention Decolonization Nursing Practice Guide Use this guide to help ensure that all nursing practice procedures and leadership support are in place to actively support the decolonization intervention. Engagement & Collaboration Determine Which Patients Need Treatment CHG Bath Docume…

2303. 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…

2304. 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

2305. Design Guide for Warm Handoff Plus (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/warm-handoff-design-guide-final508.pdf
      June 02, 2025 - Design Guide for Warm Handoff Plus The Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families Design Guide for Warm Handoff Plus Introduction In a typical primary care visit, the patient transitions from one member of the healthcare team to another multiple times, often wit…

2306. Transitioning Newborns from NICU to Home: Family Information Packet, Appendix B (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb.pdf
      June 02, 2025 - Transitioning Newborns from NICU to Home: Family Information Packet, Appendix B Appendix B: Clinical Materials to Share With Primary Care Providers Diagnoses and Conditions ■ Anemia of Prematurity ■ Apnea of Prematurity ■ Bronchopulmonary Dysplasia ■ Gastroesophageal Reflux ■ Nephrocalcinosis ■ Patent D…

2307. 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

2308. 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…

2309. 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…

2310. 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…

2311. 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

2312. 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.

2313. Developing a Community-Wide Electronic Shared Medication List (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Stock_113.pdf
      June 15, 2005 - the electronic tool by patients and clinicians; measure the degree to which medication discrepancies occurred … Electronic Medication List The clinic medication process-mapping phase and technical development of tools occurred … In summary, leadership observed that an organizational transformation occurred from fear of including … Health Care Clinics Two major improvements occurred in the clinic setting: (1) the clinic medication

2314. 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

2315. 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

2316. 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

2317. 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

2318. 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.

2319. 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.

2320. Selected Best Practices and Suggestions for Improvement (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4k_combo_psi14-dehiscence-bestpractices.pdf
      May 20, 2016 - Selected Best Practices and Suggestions for Improvement Toolkit for Using the AHRQ Quality Indicators How To Improve Hospital Quality and Safety 1 Tool D.4k Selected Best Practices and Suggestions for Improvement PSI 14: Postoperative Wound Dehiscence Why Focus on Postoperative Wound Dehiscence? • Postop…