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ce.effectivehealthcare.ahrq.gov/hai/cusp/videos/05h-why-did-happen/index.html
June 01, 2018 - Program
Comprehensive Unit-based Safety Program (CUSP)
Videos
Why Did It Happen … Videos
Decolonization – Universal and Targeted
Tools
Why Did It Happen … reviewed June 2018
Page originally created February 2013
Internet Citation: Why Did It Happen … https://www.ahrq.gov/hai/cusp/videos/05h-why-did-happen/index.html
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ce.effectivehealthcare.ahrq.gov/hai/cusp/videos/05g-what-happened/index.html
June 01, 2018 - Skip to main content
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ce.effectivehealthcare.ahrq.gov/sites/default/files/publications/files/sustainability-guideapa.pdf
January 01, 2009 - Who Should
Make This
Happen?
When Will
This
Happen? … What Other Information
Do I Need To Make This
Happen? … Who Should
Make This
Happen?
When Will
This
Happen? … What Other Information
Do I Need To Make This
Happen? … Who Should
Make This
Happen?
When Will
This
Happen?
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/resources/tools/implement/facility-action-plan.docx
January 01, 2018 - Steps
How will this happen? … Who will make this happen?
[Be specific for each task.] … What other information do I need to make this happen? … Steps
How will this happen? … What other information do I need to make this happen?
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/guides/sustainability-guideapa.pdf
January 01, 2009 - Who Should
Make This
Happen?
When Will
This
Happen? … What Other Information
Do I Need To Make This
Happen? … Who Should
Make This
Happen?
When Will
This
Happen? … What Other Information
Do I Need To Make This
Happen? … Who Should
Make This
Happen?
When Will
This
Happen?
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ce.effectivehealthcare.ahrq.gov/hai/quality/tools/cauti-ltc/modules/resources/tools/implement/action-plan.html
March 01, 2017 - Steps
How will this happen? … Who will make this happen?
[Be specific for each task.] … What other information do I need to make this happen? … Steps
How will this happen? … What other information do I need to make this happen?
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/MO_Items-Composite_Measures.pdf
October 04, 2023 - Sometimes, Most of the time, Always, Does Not Apply or Don’t Know)
How often do the following things happen … This office is good at changing office processes to make sure the same problems don’t happen again. … Mistakes happen more than they should in this office. (negatively worded)
F4. … They overlook patient care mistakes that happen over and over. (negatively worded)
E3. … In your best estimate, how often did the following things happen in your medical office OVER THE PAST
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/impguide/apd.html
February 01, 2017 - Steps
How will this happen? … [Be specific and include important steps to make the idea/activity happen.] … Who will make this happen? [Be specific for each task.] … What other information do I need to make this happen?
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/huddles/example-pdsa-form.docx
May 01, 2017 - Where will huddle happen? Default: In front of the visual management board
9. … Predict what will happen when the test is carried out (e.g., if we do “x,” “y” will happen)
Measures … When to be done
Where to be done
Predict what will happen … when the test is carried out (i.e., if we do “x,” “y” will happen)
Measures to compare prediction
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb7.html
December 01, 2017 - Resources
Injuries
Appendix B13: Pre and Posttests for Inservice #1, Why Falls Happen … Improvement Initiative for Nursing Facilities
Appendix B13: Pre and Posttests for Inservice #1, Why Falls Happen … February 2010
Internet Citation: Appendix B13: Pre and Posttests for Inservice #1, Why Falls Happen
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module2/defects.docx
March 01, 2017 - the types of systems that contributed to the defect (an event or situation that you do not want to happen … Why did it happen?
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/defects.docx
May 01, 2017 - the types of systems that contributed to the defect (an event or situation that you do not want to happen … Why did it happen?
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/learning-from-antibiotic-adverse.docx
June 01, 2021 - Events
An antibiotic-associated adverse event is any event or situation that you would not want to happen … (Why did it happen?)
Step 3. … (Why did it happen?)
Factors
Moment 1: Does the resident have symptoms that suggest an infection?
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/visual/visual-mgmt-pdsa-form.docx
May 01, 2017 - reviewed during huddle; if huddle is not scheduled regularly yet, let all relevant staff know huddle will happen … Predict what will happen when the test is carried out (e.g., if we do “x,” “y” will happen)
Measures … When to be done
Where to be done
Predict what will happen … when the test is carried out (i.e., if we do “x,” “y” will happen)
Measures to compare prediction
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/medical-office-survey-english-2023.docx
January 01, 2023 - SECTION A: List of Patient Safety and Quality Issues
The following items describe things that can happen … In your best estimate, how often did the following things happen in your medical office OVER THE PAST … They overlook patient care mistakes that
happen over and over
1
2
3
4
5
9
3. … Mistakes happen more than they should
in this office
1
2
3
4
5
9
4. … This office is good at changing office processes to make sure the same problems don’t happen again
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/pdsa-worksheet.pdf
August 20, 2018 - ______________________________________________________________________
What do you predict will happen … What do you need to do to get ready:
How will you evaluate how it went:
What do you predict will happen
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb.html
December 01, 2017 - Plan
Fall Interventions Monitor
Staff Materials
Pre and Posttests for Inservice #1, Why Falls Happen … and Posttests for Inservice #2, How to Reduce Falls
Pre and Posttests for Inservice #1, Why Falls Happen … for Inservice #2, How to Reduce Falls, Spanish
Appendix B17: Handout for Inservice #1, Why Falls Happen … Inservice #2, How to Reduce Falls in Nursing Facilities
Appendix B19: Handout for Inservice #1, Why Falls Happen
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ce.effectivehealthcare.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-slides.html
December 01, 2017 - Anything you do not want to happen again. … (From view of person involved)
Why did it happen? … Slide 15: Why Did It Happen? … Slide 16: Why Did It Happen? … Slide 22: Why Did It Happen?
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb15.html
December 01, 2017 - Resources
Injuries
Appendix B15: Pre and Posttests for Inservice #1, Why Falls Happen … Improvement Initiative for Nursing Facilities
Appendix B15: Pre and Posttests for Inservice #1, Why Falls Happen … February 2010
Internet Citation: Appendix B15: Pre and Posttests for Inservice #1, Why Falls Happen
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/sustainability/sustainability-assesment-tool.xlsx
March 01, 2017 - Who will make this happen? How do I know to move to next step? … [Be specific and include important steps to make the idea/activity happen.] … I need to make this happen? … Who will make this happen?
[Be specific for each task.] When will this happen? … What other information do I need to make this happen?