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Showing results for "happen".
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148-Investigating-Defect-Lfd-Worksheet (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/148-investigating-defect-lfd-worksheet.docxJune 02, 2025 - ___________________ Revision Date: _________________________ How Can We Reduce the Chance This Will Happen -
Sensemakingnotes (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/identify/sensemakingnotes.docxJune 02, 2025 - · Why did it happen? · What will you do to reduce risk? … categorized in three main types: skill-based, rule-based, and knowledge-based. · Skill-based failures happen … 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 We then ask why … Why did it happen? · Step 1. Visualize the factors that led to the event. · Step 2. -
www.ahrq.gov/sites/default/files/publications/files/ltcmodule2.pdfJune 01, 2012 - Sometimes systems create “an accident waiting to happen.” … Following up – The next step is being clear about what will happen after the message is given and received … Following up – The next step is being clear about what will happen after the message is given and received … Recommendation: › What should happen next? › What do you need? › Timeframe? … above the therapeutic range.” › Then, in an SBAR recommendation, say what you think might need to happen
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Changing-System-Facilitator-Guide (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-facilitator-guide.docxJune 01, 2021 - They are considered latent because they have to do with how the work environment was set up and could happen … · Why did it happen? · What could you do to reduce the risk of this happening again? … Slide 13 Why Did It Happen? -
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/composite-measures-english.pdfJanuary 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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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/SOPS-Hospital-Survey-2.0-English-05.18.21.docxJune 02, 2025 - 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
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Encinosa.pdfJanuary 01, 2003 - What Happens After a Patient Safety Event? Medical Expenditures and Outcomes in Medicare 423 What Happens After a Patient Safety Event? Medical Expenditures and Outcomes in Medicare William E. Encinosa, Fred J. Hellinger Abstract Objective: To estimate the impact of potentially preventable adverse event…
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-patient-narrative-schlesinger.pdfJune 02, 2025 - An Update on the CAHPS Patient Narrative Item Sets - Schlesinger PREVIEW OF NEW NARRATIVE ITEM SETS IN DEVELOPMENT Mark Schlesinger, PhD A Growing Family of Narrative Item Sets CG-CAHPS Narrative Item Set Health Plan Narrative Item Set Inpatient Narrative Items: For Child HCAHPS 19 The Health Plan Narr…
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www.ahrq.gov/sops/international/nursing-home/translators.htmlOctober 01, 2014 - 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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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospitalsurvey2-items.pdfJune 02, 2025 - 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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www.ahrq.gov/hai/cusp/modules/identify/index.htmlJuly 01, 2018 - Why Did It Happen? (34 sec.) What Will You Do to Reduce the Risk of Recurrence? (40 sec.)
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www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/graber-summit2016.pdfJanuary 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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www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/gdmodap2a.htmlOctober 01, 2014 - Recommendation: What should happen next? What do you need? Timeframe?
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091-Decolonization-Implementation-Fg (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/091-decolonization-implementation-fg.docxApril 01, 2025 - Slide 6 Where Does Decolonization Happen? … This tool asks four important questions: what happened, why did it happen, how to reduce the likelihood … The next question was to investigate is, why did it happen? … next step in the process is to develop an intervention to reduce the likelihood that this risk will happen -
129-Ss-Blank-Lfd (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/129-ss-blank-lfd.docxApril 01, 2025 - A defect is any clinical or operational event or situation that you would not want to happen again. … Why Did It Happen? Below is a framework to help you review and evaluate your case. -
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/SOPS-Hospital-Survey-2.0-5-26-2021.pdfJanuary 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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www.ahrq.gov/hai/cusp/videos/index.htmlSeptember 01, 2019 - Why Did It Happen?
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SOPS® Nursing Home Survey on Patient Safety (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursing-home-survey-english.docxSeptember 01, 2024 - reporting their mistakes 1 2 3 4 5 9 SECTION B: Communications How often do the following things happen … again 1 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. -
SOPS® Nursing Home Survey on Patient Safety (pdf file)
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursing-home-survey-english.pdfSeptember 01, 2024 - 1 2 3 4 5 9 SECTION B: Communications How often do the following things happen in your nursing … 1 2 3 4 5 9 3 SECTION B: Communications (continued) How often do the following things happen … This nursing home lets the same mistakes happen again and again ............................. -
www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-slides.pptxJune 01, 2021 - Why did it happen? What could you do to reduce the risk? How do you know that risk was reduced? … Imagine the world as they did when the event occurred. 13 Changing the System 13 Why Did It Happen
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