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21. Prioritization Worksheet (pdf file)
    www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheetinstructions.pdf
    June 05, 2016 - column E, “Volume of Cases at Risk,” indicate the annual volume of each PSI, IQI, and/or PDI event occurring … This number is the total raw number of events occurring within your organization for your chosen time

22. Register Your Network | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/ncepcr/communities/pbrn/registry/register.html
    January 01, 2022 - Register Your Network Register Your Network Recognizing the tremendous growth occurring

23. Module 1: An Overview of the CANDOR Process | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes1.html
    August 01, 2022 - clinicians understand what a CANDOR event is and what to do when they recognize that a CANDOR event is occurring

24. TeamSTEPPS Mutual Support Module 4
    www.monahrq.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/curriculum/teamstepps-module-4-slides.pptx
    February 28, 2022 - Directed toward improvement: Helps prevent the same problem from occurring in the future.

25. Comparison Tables for Making Healthcare Safer Reports | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/research/findings/making-healthcare-safer/comparison.html
    September 01, 2022 - National Academy of Medicine report that elevated awareness of longstanding risks and patient harms occurring … inaugural report consisted of 50 patient safety practices in eight categories encompassing commonly occurring

26. AHRQ Expands Its Repertoire to Eliminate Diagnostic Errors | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/news/blog/ahrqviews/eliminate-diagnostic-errors.html
    August 01, 2022 - Some signs suggest that progress is occurring.

27. Surge in Drug Shortages Occurred in Wake of Pandemic, Study Finds | Agency for Healthcare Research and Quality
    www.monahrq.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 …

28. AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Sensemaking and Learn from Defects
    www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/sensemaking.pptx
    May 01, 2017 - happen again CUSP and Sensemaking tools help teams identify defects and identify ways to deter them from occurring

29. AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Under the Science of Safety
    www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-science-safety.pptx
    May 01, 2017 - Divergent thinking occurs during brainstorming sessions and when trying to understand what might be occurring

30. Module 4: Event Reporting, Event Investigation and Analysis | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes4.html
    August 01, 2022 - best practice of creating a hotline for staff to call when they feel a CANDOR event has occurred or is occurring

31. Major Hospital Quality Measurement Sets | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/talkingquality/measures/setting/hospitals/measurement-sets.html
    February 01, 2023 - The Patient Safety Indicators (PSIs) identify adverse events occurring during hospitalization.

32. Medication Discrepancies and Potential Adverse Drug Events During Transfer of Care from Hospital to Home | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/patient-safety/reports/liability/neumiller.html
    August 01, 2017 - several studies have highlighted the significant liability claim costs associated with preventable ADEs occurring … claims analyzed, 73 percent of them were deemed preventable and were nearly evenly divided between ADEs occurring … This project highlights the need to proactively implement strategies to minimize potential ADEs occurring

33. Learn-From-Defects-Facilitator-Guide (doc file)
    www.monahrq.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 - CUSP and Sensemaking tools help teams identify defects and identify ways to prevent them from occurring

34. Action Planning Worksheets | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/teamstepps/instructor/essentials/implguide2.html
    November 01, 2018 - 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 …

35. Sensemaking and Learn from Defects for Perinatal Safety (pdf file)
    www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.pdf
    May 01, 2017 - • CUSP and Sensemaking tools help teams identify defects and identify ways to prevent them from occurring

36. Health Care Simulation to Advance Safety: AHRQ Issue Brief (pdf file)
    www.monahrq.ahrq.gov/sites/default/files/publications/files/simulation-brief.pdf
    February 01, 2015 - Simulation The simulation community has witnessed tremendous growth and energy in the past 15 years, occurring … should concerns relating to variable patient acuity, complexity of operations, and less frequently occurring

37. Data Infographics | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/data/infographics/index.html
    March 01, 2024 - Employer-Sponsored Health Insurance Growing Pain of Spinal Stenosis Adverse Drug Events Occurring

38. 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013 | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/hai/pfp/hacrate2013.html
    January 01, 2018 - incidents of harm occurred in 2011, 2012, and 2013 (compared to 2010), with most of the improvement occurring

39. TeamSTEPPS for Office-Based Care: Implementation Workbook | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/teamstepps/officebasedcare/impworkbook.html
    December 01, 2015 - 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 …

40. TeamSTEPPS® for Office-Based Care - Readiness Assessment (pdf file)
    www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/officebasedcare/handouts/readiness.pdf
    August 01, 2005 - Identify the changes that are occurring or will occur during the timeframe within which TeamSTEPPS implementation … Identify any current safety and quality initiatives (e.g., Lean Six Sigma) that may already be occurring