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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/implementation-guide/appendix-j.pdf
April 13, 2017 - Implementation Guide Appendix J Coaching Tool Instructions and Observation Tool With Coaching Section
AHRQ Safety Program for Ambulatory Surgery
Appendix J. Coaching Tool Instructions and
Observation Tool With Coaching Section
After using the observation tool to collect information regarding the processes perfor…
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/nursing-home/resources/infotransNHSOPS.pdf
January 01, 2010 - expect supervisors to
investigate all factors, including systems reasons, to determine why mistakes happen … Sometimes, Most of the time, Always, Does Not Apply or Don’t Know)
How often do the following things happen … Sometimes, Most of the time, Always, Does Not Apply or Don’t Know)
How often do the following things happen … Sometimes, Most of the time, Always, Does Not Apply or Don’t Know)
How often do the following things happen … This nursing home lets the same mistakes happen again and again. (negatively worded)
D4.
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ce.effectivehealthcare.ahrq.gov/health-literacy/improve/precautions/tool5b.html
March 01, 2024 - "Just to make sure that I explained things well, can you tell me in your own words what will happen if … Can you tell me in your own words what might happen?"
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ce.effectivehealthcare.ahrq.gov/talkingquality/distribute/promote/multiple/using-media.html
September 01, 2019 - Bad press can happen because the people you worked with didn’t take the time to understand your work, … While any of these misfortunes can happen, they are not reasons to avoid working with the media entirely … Bad press can happen to anyone.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/attitudes-beliefs-transcript.pdf
April 01, 2022 - So, it can happen. And it does happen.
And there's plenty in the literature. … that help us to get there,
that improve teamwork, improve communication, that all show that this can
happen … So, we know it can happen. … So, to share successes like that, yes, it
does happen.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/20140603_QI/3_rachel_grob.pdf
June 25, 2014 - past 12 months)
Positive experiences: 1 Question with
narrative guide (what happened, how did it
happen … (past 12 months)
Positive experiences: 1 Question with narrative guide
(what happened, how did it happen
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-facilitator-guide.docx
May 01, 2017 - The first step in comprehending why they happen is accepting that people are not perfect. … Why did it happen?
What will we do to reduce the recurrence?
How will we know it worked? … Why did it happen?
How will you reduce the risk of recurrence?
How will you know it worked?
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-fac-guide.html
July 01, 2023 - Why did it happen?
What will you do to reduce risk? … The consequent event is described in terms of the event's consequences:
Harm that did happen. … Harm that did not happen—No-harm event.
Event did not reach the patient—Near-miss event. … Why did it happen?
Step 1. Visualize the factors that led to the event.
Step 2. … Defects are clinical or operational events that you do not want to happen again.
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/modules/checklist5.html
August 01, 2022 - Skip to main content
An official website of the Department of Health and Human Services
Careers
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ce.effectivehealthcare.ahrq.gov/diagnostic-safety/index.html
January 01, 2007 - Diagnostic Safety and Quality
Learn about AHRQ's research to better understand how diagnostic errors happen … AHRQ funds research to better understand how diagnostic errors happen and what can be done to prevent
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nh-survey-06-16-21.doc
June 16, 2021 - mistakes
(1
(2
(3
(4
(5
(9
SECTION B: Communications
How often do the following things happen … (2
(3
(4
(5
(9
SECTION B: Communications (continued)
How often do the following things happen … This nursing home lets the same mistakes happen again and again
(1
(2
(3
(4
(5
(9
4.
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/understand-sci-fac-guide.html
July 01, 2023 - Slide 4: How Can These Errors Happen? … The first step in comprehending why they happen is accepting that people are not perfect. … Why did it happen?
What will we do to reduce the recurrence?
How will we know it worked? … Why did it happen?
How will you reduce the risk of recurrence?
How will you know it worked?
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/patient-narratives-webinar-ahrq.pdf
May 23, 2022 - care
Standardized surveys: What happened to the patient in the care
encounter, or how often did it happen
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ce.effectivehealthcare.ahrq.gov/hai/cusp/toolkit/learn-defects.html
December 01, 2012 - A defect is any clinical or operational event or situation that you would not want to have happen again … Why did it happen? Below is a framework to help you review and evaluate your case.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/graber-summit2016.pdf
January 01, 2017 - devastating consequences.”
1 in 20 chance per year X 80 years = approximately 100%
Where do they happen … Arch Int Med 165:1493-9, 2005
Why do they happen? … safety challenge�
Slide Number 28
Slide Number 29
Slide Number 30
Slide Number 31
Where do they happen
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/nyp-webinar-grob-narrative-elicitation-protocol.pdf
October 29, 2018 - Implementing the New CAHPS® Protocol for Obtaining Patient Comments About Their Care
The CAHPS Narrative Elicitation
Protocol
Rachel Grob, Ph.D.
Director of National Initiatives and Clinical Professor,
Center for Patient Partnerships
Madison, WI
www.ahrq.gov/cahps
CAHPS Narrative Elicitation Protocol
• A …
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/modules.html
August 01, 2022 - Module 7: Resolution
Module 8: Organizational Learning and Sustainability
“We realize mistakes happen … Harms such as hospital-acquired infections or medication errors can happen during any stage of care.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/SOPS-Hospital-Survey-2.0-5-26-2021.pdf
January 01, 2021 - 1 2 3 4 5 9
SECTION C: Communication
How often do the following things happen in your unit … We are informed about errors that happen in
this unit ............................................ … When errors happen in this unit, we discuss
ways to prevent them from happening again .. 1 2 3 4
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/learning_pt_narratives_053123-ginsberg.pdf
July 03, 2023 - surveys measure experience:
► What happened to the patient in the care encounter, or how often did it happen
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ce.effectivehealthcare.ahrq.gov/cahps/surveys-guidance/item-sets/ch/suppl-narrative-items-child-hospital-survey.html
November 01, 2023 - Skip to main content
An official website of the Department of Health and Human Services
Careers
Contact Us
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FAQs
Search all AHRQ sites
Search small
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…