-
pcmh.ahrq.gov/patient-safety/settings/hospital/candor/grand-rounds.html
August 01, 2022 - physician, and/or care provider to be fully transparent when an error occurs, but often this doesn't happen … It is important to understand that communication doesn't happen just once and then you are done; rather
-
pcmh.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/2020_MOSOPS_Part_I-rev0921.pdf
January 01, 2020 - (F2)
Mistakes happen more than they should
in this office . … (E1R)
They overlook patient care mistakes that
happen over and over. … 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. … They overlook patient care mistakes that happen over
and over.
-
pcmh.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes6.html
August 01, 2022 - The second-victim is often fearful at this point about what is going to happen next and whether or not … clinical staff involved in the event, notify clinical staff involved in the event what is going to happen
-
pcmh.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/pharmsops-composites.pdf
June 19, 2018 - We look at staff actions and the way we do things to understand why mistakes happen in this
pharmacy
-
pcmh.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/item-sets/administering-child-hcahps-narrative-items.pdf
November 01, 2023 - Administering the CAHPS Child Hospital Narrative Item Set
Administering the CAHPS® Child Hospital
Narrative Item Set
November 2023
Introduction ..................................................................................................................... 1
Deciding Whether to Use Narrative Items .........…
-
pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/simulation/simslides-update-62819.ppt
January 30, 2006 - Processes answer the question “Why did it happen?”
-
pcmh.ahrq.gov/patient-safety/index.html
January 01, 2024 - Diagnostic Safety and Quality
Funding research to better understand how diagnostic errors happen
-
pcmh.ahrq.gov/teamstepps/simulation/traininggd1.html
July 01, 2016 - and “Why did it happen? ”
(3 min.)
-
pcmh.ahrq.gov/health-literacy/professional-training/informed-choice/audio-script.html
September 01, 2020 - Can you tell me in your own words what might happen?” … What might happen then? … Doctor: Yes…that could unfortunately happen. … Doctor: That could happen. … How likely are they to happen?
-
pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/mod5-comm-assessment.pdf
April 01, 2016 - stable; her heart rate, blood pressure, and oxygen level are all in normal ranges, but something did happen
-
pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/resources/asc-survey.pdf
June 06, 2018 - Staff are told about patient safety problems that
happen in this facility ......................... … We are good at changing processes to make sure
the same patient safety problems don’t happen again.
-
pcmh.ahrq.gov/talkingquality/distribute/promote/multiple/advertise.html
September 01, 2019 - Recommended resource: Why Bad Ads Happen to Good Causes .
-
pcmh.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/job-aid-5-whys.pdf
May 17, 2021 - Ask "Why does this happen?" to stimulate brainstorming.
-
pcmh.ahrq.gov/hai/cusp/modules/patient-family-engagement/notes.html
September 01, 2013 - Medical providers are committed to caring for their patients; however, adverse events can happen.
-
pcmh.ahrq.gov/news/blog/ahrqviews/long-covid.html
March 01, 2023 - its National Advisory Council, where we will continue to address these critical matters to make that happen
-
pcmh.ahrq.gov/hai/tools/surgery/guide-surg-comp.html
December 01, 2017 - Identification and Mitigation Tool ( Word , 1.73 MB)
Understand where, when, and why workarounds happen
-
pcmh.ahrq.gov/sites/default/files/attachments/ContextualFactors.pdf
June 01, 2013 - manifested in different settings, situations,
and stakeholders.1 Understanding the PCMH and making it happen
-
pcmh.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-webinar-jan-2017-schlesinger.pdf
January 01, 2017 - CAHPS Elicitation Protocol Webcast
Development and Testing of
the CAHPS Elicitation Protocol
Mark Schlesinger
Yale School of Public Health
www.ahrq.gov/cahps
Goals for narrative elicitation: specifics
We aspired to collect narratives that are:
• Complete: provide a full picture of the experiences that
matter…
-
pcmh.ahrq.gov/teamstepps-program/curriculum/communication/overview/index.html
June 01, 2023 - ownership
Situation Awareness & Contingency Planning
Know what’s going on
Plan for what might happen
-
pcmh.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/2022-mosops-database-report-part-I.pdf
January 01, 2022 - (Item Fl)
This office is good at changing office processes to make
sure the same problems don't happen … (Item F2)
Mistakes happen more than they should in this office. … (Item E1*)
They overlook patient care mistakes that happen over
and over. … (Item F2)
84% 17.23% 17% 60% 75% 88% 100% 100% 100%
% Disagree/Strongly Disagree
Mistakes happen … (Item E1*)
44% 25.03% 0% 12% 25% 43% 62% 75% 100%
They overlook patient care mistakes that happen