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www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb15.html
December 01, 2017 - Improvement Initiative for Nursing Facilities
Appendix B15: Pre and Posttests for Inservice #1, Why Falls Happen
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www.ahrq.gov/talkingquality/translate/scores/scoring.html
June 01, 2016 - Do you want to tell people how often this event happened or how often it did not happen? … Experience indicates that in this case, saying how often a patient safety event did happen will be
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www.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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www.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.
-
www.ahrq.gov/sites/default/files/publications/files/ltcmodule2.pdf
June 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
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/148-investigating-defect-lfd-worksheet.docx
June 02, 2025 - ___________________
Revision Date: _________________________
How Can We Reduce the Chance This Will Happen
-
www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-facilitator-guide.docx
June 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?
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-patient-narrative-schlesinger.pdf
June 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/sites/default/files/wysiwyg/sops/surveys/hospital/hospitalsurvey2-items.pdf
June 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/sites/default/files/wysiwyg/sops/surveys/hospital/SOPS-Hospital-Survey-2.0-English-05.18.21.docx
June 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/sops/surveys/asc/composite-measures-english.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.
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/gdmodap2a.html
October 01, 2014 - Recommendation:
What should happen next?
What do you need?
Timeframe?
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb17.html
December 01, 2017 - Quality Improvement Initiative for Nursing Facilities
Appendix B17: Handout for Inservice #1, Why Falls Happen
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/091-decolonization-implementation-fg.docx
April 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
-
www.ahrq.gov/sops/international/nursing-home/translators.html
October 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.
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/129-ss-blank-lfd.docx
April 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/hai/cusp/modules/identify/index.html
July 01, 2018 - Why Did It Happen? (34 sec.)
What Will You Do to Reduce the Risk of Recurrence? (40 sec.)
-
www.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
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursing-home-survey-english.docx
September 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.
-
www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-slides.pptx
June 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