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Total Results: 2,150 records

Showing results for "happen".

101. Engage the Team and Applying CUSP in the ICU Setting Slides (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cusp-icu-notes.docx
     April 01, 2022 - As we discussed at the beginning of this presentation, staff need a clear understanding of what will happen … · Why did it happen? · How will you reduce the risk of the defect happening again? … Slide 14 In order for the CUSP team to better understand why defects happen, make the "whys" visual

102. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/088-or-traffic.pptx
     April 01, 2025 - Why did it happen? How to reduce the likelihood of this defect happening again? … discussion focused around OR traffic Members felt that door openings during the surgical case appeared to happen … AHRQ Safety Program for MRSA Prevention | Surgical Services OR Traffic 14 Case Example: Why Did It Happen

103. 114-Mrsa-Prevention-Learning-From-Defects (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/114-mrsa-prevention-learning-from-defects.docx
     October 01, 2024 - A defect is any clinical or operational event that you would not want to happen again. … Why did it happen?

104. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/module5-response-disclosure-notes.pptx
     August 21, 2015 - Why did it happen? How will the organization prevent the event from happening to another patient? … Why did the event happen? … issue and redirect the conversation toward a shared goal of ensuring that a similar event does not happen

105. Understand the Science of Safety for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/understand-sci-fac-guide.html
     July 01, 2023 - Slide 4: How Can These Errors Happen? … The first step in comprehending why they happen is accepting 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?

106. Sensemaking and Learn From Defects for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/perinatal-care/modules/teamwork/learn-from-defects-fac-guide.html
     May 01, 2017 - Why did it happen? What will you do to reduce risk? … 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. … Why did it happen? Step 1. Visualize the factors that led to the event. Step 2. … Defects are clinical or operational events that you do not want to happen again.

107. Learn-From-Defects-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.docx
     May 01, 2017 - Why did it happen? What will you do to reduce risk? … Skill-based failures happen when a person fails in the performance of a routine task that normally requires … The consequent event is described in terms of the event’s consequences: Harm that did happen Harm that … Why did it happen? Step 1. Visualize the factors that led to the event. Step 2. … Defects are clinical or operational events that you do not want to happen again.

108. Approach to Residents With Reported Penicillin Allergy (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/penicillin-allergy.pdf
     June 01, 2021 - _______________ o How soon after starting the antibiotic did the reaction happen (e.g., minutes to hours … by: Datetime: Reviewed by physician: How soon after starting the antibiotic did the reaction happen

109. The Comprehensive Unit-based Safety Program (CUSP) for MRSA Prevention | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mrsa-prevention/toolkit/cusp.html
     October 01, 2024 - Assessment The Premortem Tool is a proactive way to anticipate risks and failures before they actually happen … Learning From Defects A "defect" is defined as "Anything that you don't want to have happen again."

110. Background and Information for Translators of the AHRQ Hospital Survey on Pateint Safety Culture Version 2.0 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospital/sops-hsops-2-translation-guidelines.pdf
     August 01, 2023 - (negatively worded) • More about this item: When patient safety problems happen, this unit does not … do anything to ensure the problem does not happen again. 4. … negatively worded) • More about this item: Staff feel like they are unfairly blamed when mistakes happen … 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.

111. Appendix B19: Handout for Inservice #1, Why Falls Happen, Spanish | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/fallspxmanapb19.html
     December 01, 2017 - Quality Improvement Initiative for Nursing Facilities Appendix B19: Handout for Inservice #1, Why Falls Happen

112. 148-Investigating-Defect-Lfd-Worksheet (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/148-investigating-defect-lfd-worksheet.docx
     August 08, 2024 - ___________________ Revision Date: _________________________ How Can We Reduce the Chance This Will Happen

113. Appendix B15: Pre and Posttests for Inservice #1, Why Falls Happen, Spanish | Agency for Healthcare Research and Quality
     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

114. Improving Patient Safety in Long-Term Care Facilities, Module 2 (pdf file)
     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

115. Changing-System-Facilitator-Guide (doc file)
     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?

116. Using Mass Media To Spread Messages About a Quality Report | Agency for Healthcare Research and Quality
     www.ahrq.gov/talkingquality/distribute/promote/multiple/using-media.html
     September 01, 2019 - Bad press can happen because the people you worked with didn’t take the time to understand your work, … While any of these misfortunes can happen, they are not reasons to avoid working with the media entirely … Bad press can happen to anyone.

117. Learndefects (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/learndefects.doc
     August 08, 2012 - A defect is any clinical or operational event or situation that you would not want to have happen again … Why did it happen? Below is a framework to help you review and evaluate your case.

118. Sensemaking and Learn from Defects for Perinatal Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.pdf
     May 01, 2017 - • Why did it happen? • What will you do to reduce risk? … • Skill-based failures happen when a Slide 4 Sensemaking and Learn From Defects for Perinatal … The consequent event is described in terms of the event’s consequences: • Harm that did happen • … Why did it happen? • Step 1. Visualize the factors that led to the event. • Step 2. … • Defects are clinical or operational events that you do not want to happen again.

119. Appendix 2-A. Suggested Slides for Module 2 | Agency for Healthcare Research and Quality
     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?

120. An Update on the CAHPS Patient Narrative Item Sets - Schlesinger (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-patient-narrative-schlesinger.pdf
     December 14, 2021 - 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…