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www.ahrq.gov/hai/tools/surgery/modules/sustainability/premortem-fac-notes.html
December 01, 2017 - Slide 8: Premortem Exercise
Say:
In step two, consider the reasons that caused your project to … What could have caused our project to fail? … What could have caused your project to fail?
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www.ahrq.gov/teamstepps-program/curriculum/communication/tools/checkback.html
July 01, 2023 - Delayed diagnoses that sometimes cause serious patient harm are often caused by a provider overlooking … Watch this patient video discussing how a misunderstood message caused patient distress and how a check-back
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_premortem_facnotes.docx
December 01, 2017 - Slide 7
Premortem Exercise
SAY:
In step two, consider the reasons that caused your project to fail … What could have caused our project to fail? … What could have caused your project to fail?
3.
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www.ahrq.gov/sites/default/files/wysiwyg/nhguide/6_TK1_T4-Be_Smart_About_Antibiotics_Final.pdf
May 01, 2014 - Antibiotics can help the body fight infections caused by germs called
bacteria, but they are not miracle … When antibiotics are NOT needed:
• You have an infection caused by a virus (such as a cold, bronchitis
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www.ahrq.gov/hai/tools/surgery/modules/sustainability/premortem-slides.html
December 01, 2017 - Ask your team:
What could have caused our project to fail? … What could have caused your project to fail?
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/premortem-tool.docx
January 01, 2017 - What could have caused this?” … What could have caused this? … REASONS FOR FAILURE
What could have caused this?
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www.ahrq.gov/hai/tools/mvp/modules/cusp/premortem-tool.html
January 01, 2017 - What could have caused this?" … What could have caused this? … REASONS FOR FAILURE
What could have caused this?
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/hospitals/red-toolkit/dxpages.docx
June 02, 2025 - Examples of Diagnosis Pages
Noncardiac Chest Pain
Noncardiac chest pain is pain that is not caused
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/hospitals/red-toolkit/dxpages.pdf
June 02, 2025 - 4
5
6
Noncardiac Chest Pain
Noncardiac chest pain is pain that is not caused
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www.ahrq.gov/funding/grantee-profiles/grtprofile-walsh.html
October 01, 2023 - Her Ambulatory Pediatric Safety Learning Lab focuses on preventing harm in children caused by the outpatient … The team received the award for its substantial reduction in preventable harm caused by healthcare to
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www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/handouts/staff-mupirocin.pdf
March 01, 2022 - • Most S. aureus infections are caused by bacteria in the
patient’s own nose.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/handouts/staff-mupirocin.docx
March 01, 2022 - .
· Most S. aureus infections are caused by bacteria in the patient’s own nose.
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/one-pager-bacterial-pneumonia.pdf
June 01, 2021 - pain with breathing) in the chest, upper abdomen, or back3
In adults, about 75% of pneumonia is caused … by bacteria and 25% is caused by viruses4
• A positive test for a respiratory virus (e.g., influenza
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www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/handouts/staff-iodophor.docx
March 01, 2022 - .
· Most S. aureus infections are caused by bacteria that live in the patient’s own nose.
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/handouts/staff-iodophor.pdf
March 01, 2022 - • Most S. aureus infections are caused by bacteria that live in
the patient’s own nose.
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www.ahrq.gov/hai/cauti-tools/phys-championsgd/section3.html
October 01, 2015 - walk)
Ultimately, the patient underwent back surgery to decompress the pressure on the spinal cord caused … The virulent organism caused a severe infection and irreversible injury to the patient.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/035-importance-mrsa-prevention-notes.docx
October 01, 2024 - Laboratory-identified (LabID) MRSA bacteremia is a publicly reported HAI, and CLABSI caused by MRSA adds … HAIs, including those caused by MRSA, not only cause patient harm, but can negatively impact hospitals … Antibiotic pressure, caused by treating patients with courses of antibiotics with activity against S. … carriers experienced invasive MRSA disease in the subsequent year, and that 17 percent of these infections caused
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/034-importance-mrsa-prevention-slides.pptx
October 01, 2024 - HAIs, including those caused by MRSA:
Cause patient harm.
Are publicly reported. … carriers experienced invasive MRSA disease in the subsequent year, and 17 percent of these infections caused … Evidence-based interventions should be used to prevent device- and procedure-related infections that are often caused … Hospitalizations and deaths caused by methicillin-resistant Staphylococcus aureus, United States, 1999
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit2-15.html
November 01, 2014 - composition and size
"Fresh eyes" on the team suggested solutions that were not feasible and may have caused
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/family-RTI.pdf
June 01, 2021 - • If she has a cough without fever or difficulty breathing, she may have a
chest cold, caused by