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preventiveservices.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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preventiveservices.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?
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preventiveservices.ahrq.gov/sops/international/medical-office/translators.html
January 01, 2010 - in the past 12 months, Does Not Apply or Don't Know)
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. … 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.
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/patients-consumers/care-planning/errors/20tips/20tips.pdf
September 01, 2011 - They can happen during
even the most routine tasks, such as when a hospital
patient on a saltfree … But errors also happen
when doctors* and patients have problems
communicating. … If you know
what might happen, you will be better prepared
if it does or if something unexpected happens
-
preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/identify/sensemaking.pptx
January 01, 2006 - Why did it happen?
3. What will you do to reduce the risk of recurrence?
4. … 22
Why Did It Happen?
23
What Will You Do To Reduce the Risk of Recurrence? … several common themes
Defects or failures are clinical or operational events that you do not want to happen
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preventiveservices.ahrq.gov/hai/cusp/modules/identify/identify.html
December 01, 2012 - Why Did It Happen? Slide 24. What Will You Do To Reduce the Risk of Recurrence? Slide 25. … Why did it happen?
What will you do to reduce the risk of recurrence? … (vignette still)
Click to play
Return to Contents
Slide 23: Why Did It Happen? … Defects or failures are clinical or operational events that you do not want to happen again.
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preventiveservices.ahrq.gov/hai/cusp/modules/identify/notes.html
December 01, 2012 - Why Did It Happen? Slide 24. What Will You Do To Reduce the Risk of Recurrence? Slide 25. … Why did it happen?
What will you do to reduce risk? … Why did it happen?
Step 1. Visualize the factors that led to the event.
Step 2. … Return to Contents
Slide 23: Why Did It Happen?
Do:
Play the video. … Defects are clinical or operational events that you do not want to happen again.
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preventiveservices.ahrq.gov/questions/resources/20-tips.html
November 01, 2020 - They can happen during even the most routine tasks, such as when a hospital patient on a salt-free diet … But errors also happen when doctors * and patients have problems communicating. … If you know what might happen, you will be better prepared if it does or if something unexpected happens
-
preventiveservices.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/notes.html
August 01, 2022 - Why did the event happen? … issue and redirect the conversation toward a shared goal of ensuring that a similar event does not happen
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospitalsurvey2-items.pdf
August 01, 2019 - We are informed about errors that happen in this unit.
C2. … When errors happen in this unit, we discuss ways to prevent them from happening again.
C3.
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preventiveservices.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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preventiveservices.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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preventiveservices.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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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/patient-safety/resources/diagnostic-toolkit/03-diagnostic-safety-infographic.pdf
August 01, 2021 - Did You Know, Safety Infographic
Did you know...
57%
of all diagnostic
failures happen in
ambulatory
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy3/Strat3_Tool_1_BSR_Broch_508.pdf
May 23, 2013 - • If nurse bedside shift report does not
happen, call the nurse manager at [insert
phone number]
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/SOPS-Hospital-Survey-2.0-English-05.18.21.docx
June 09, 2016 - their attention
1
2
3
4
5
9
SECTION C: Communication
How often do the following things happen … We are informed about errors that happen in this unit
1
2
3
4
5
9
2. … When errors happen in this unit, we discuss ways to prevent them from happening again
1
2
3
4
5
-
preventiveservices.ahrq.gov/hai/cusp/modules/understand/science-safety-notes.html
July 01, 2018 - How Can These Errors Happen?
Slide 6. The Science of Safety
Slide 7. … Return to Contents
Slide 5: How Can These Errors Happen? … The first step in comprehending why they happen is accepting the fact 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?
-
preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy3/Strat3_Tool_1_BSR_Broch_508.docx
February 24, 2011 - If nurse bedside shift report does not happen, call the nurse manager at [insert phone number].
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/resources/asc-items.pdf
January 01, 2015 - We are good at changing processes to make sure the same patient safety problems don’t happen again. … Staff are told about patient safety problems that happen in this facility.
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preventiveservices.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/implementation-guide/app-j.html
May 01, 2017 - Skip to main content
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