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www.ahrq.gov/hai/cusp/videos/05h-why-did-happen/index.html
June 01, 2018 - Why Did It Happen?
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www.ahrq.gov/hai/cusp/videos/05g-what-happened/index.html
June 01, 2018 - What Happened?
CUSP Toolkit
The CUSP toolkit includes training tools to make care safer by improving the foundation of how your physicians, nurses, and other clinical team members work together. These videos reinforce the material presented in each module of the CUSP toolkit.
CUSP Helps Find Out What Hap…
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www.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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www.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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www.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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www.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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www.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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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/defects.html
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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www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module2/defects.html
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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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/learn.html
April 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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www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb.html
December 01, 2017 - 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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www.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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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/action-plan-template.docx
April 01, 2022 - How will this happen? … [Be specific and include important steps to make the idea/activity happen.]
_________________________ … Who will make this happen?
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/024-ss-cusp-learning-from-defects.pptx
April 01, 2025 - Defects: Clinical or operational events or situations that you do not want to happen again
Examples of … Why did it happen?
How will you reduce the likelihood of this defect from happening again? … Program for MRSA Prevention | Surgical Services
Learning From Defects
11
Question Two
Why Did It Happen … MRSA Prevention | Surgical Services
Learning From Defects
Learning From Defects Process: Why Did It Happen … Why did it happen?
How will you reduce the likelihood of this defect happening again?
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/management/huddles-pdsa-form.html
June 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 …
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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www.ahrq.gov/hai/tools/mrsa-prevention/surgery/learning-from-defects.html
April 01, 2025 - According to CUSP, a defect is broadly defined as “Anything you do not want to happen again.” … Why did it happen? What will we do to reduce the risk of this happening again?
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www.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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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/management/pdsa-form.html
June 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 …
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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www.ahrq.gov/funding/policies/informedconsent/icform4.html
September 01, 2009 - the Research and Protocol "Tell me in your own words about the goal of this research and what will happen … ___ Voluntariness " What do you think will happen to you if you refuse to be in this study?" … "What will happen to information already gathered if you change your mind?"
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www.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?