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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-surgery/019-perioperative-infection-prevention-strategies-notes.docx
April 01, 2025 - · Why did it happen?
· How do we reduce the likelihood of this happening again? … Slide 32
Case Example: Why Did it Happen?
SAY:
So, why did it happen?
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www.ahrq.gov/funding/policies/informedconsent/icform1.html
September 01, 2009 - You can stop answering our questions at any time and nothing will happen to you.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/contentcalls/briefing-slides/Morning-Briefing-and-Shadowing-July-12-2011-508.ppt
January 01, 2011 - -- An Overview
Members of the team have an understanding of what’s going on and what is likely to happen … procedure
Establishes competence
Who has what skills
Who performs what
Who knows what
Predicts what will happen
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www.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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www.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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www.ahrq.gov/funding/grantee-profiles/devoe-transcript.html
April 01, 2016 - K Award Grantee Interview: Jennifer DeVoe, M.D., D.Phil.
Transcript
The following is a transcript of grantee responses to the following questions:
What is the primary focus of your research?
How has funding from AHRQ helped to advance your research?
Why did you choose to focus on this topic?
How has y…
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www.ahrq.gov/teamstepps-program/curriculum/communication/tools/ipass.html
July 01, 2023 - ownership
S ituation Awareness & Contingency Planning
Know what's going on
Plan for what might happen
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/learning_pt_narratives_053123-ginsberg.pdf
July 03, 2023 - surveys measure experience:
► What happened to the patient in the care encounter, or how often did it happen
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/coaching-slides.html
May 01, 2017 - "Can you help me understand why that didn't happen?
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/103-how-to-integrate-cusp-approach-periop-fg.docx
April 01, 2025 - A defect is defined as anything “you do not want to happen again.” … What happened, why did it happen using system lenses, what could you do to reduce the risk of it happening … An effective CUSP team knows mistakes happen and is committed to being vigilant to prevent them—and when
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apd.html
August 01, 2022 - FUTURE RISKS
Are there other areas in the organization where this could happen?
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www.ahrq.gov/cpi/about/otherwebsites/qualityindicators.ahrq.gov/takeheart.html
January 01, 2021 - not to refer eligible patients, and a trained liaison (care coordinator) who helps make the referrals happen
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www.ahrq.gov/hai/cauti-tools/cauti-icu/facil-guide/mod3-slides.html
February 01, 2023 - Slide 5
What Do You Think Will Happen?
Images: Photo of "Nurse Sally" and "Nurse Molly."
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www.ahrq.gov/hai/cusp/modules/understand/science-safety-slides.html
July 01, 2018 - How Can These Errors Happen?
Slide 6. The Science of Safety
Slide 7. … line-associated blood stream infections per year. 8
Return to Contents
Slide 5: How Can These Errors Happen … Why did it happen?
How will you reduce the risk of recurrence?
How will you know it worked?
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www.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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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/family-antibiotics.pdf
June 01, 2021 - Allergic reactions don’t happen often, but when they do they
can cause people to feel pretty uncomfortable
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/ap2.html
August 01, 2022 - stable; her heart rate, blood pressure, and oxygen level are all in normal ranges, but something did happen
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/2024-medical-office-database-report.pdf
January 01, 2024 - (Item F2) 84%
Mistakes happen more than they should in this office. … (Item E1*)
46%
They overlook patient care mistakes that happen over and over. … In your best estimate, how often did the following things happen in your
medical office OVER THE PAST … In your best estimate, how often did the following things happen in your
medical office OVER THE PAST … (Item E1*)
46% 23.11% 0% 17% 30% 45% 63% 75% 100%
They overlook patient care mistakes that happen
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/2024-medical-office-database-report-rev.pdf
January 01, 2024 - (Item F2) 84%
Mistakes happen more than they should in this office. … (Item E1*)
46%
They overlook patient care mistakes that happen over and over. … In your best estimate, how often did the following things happen in your
medical office OVER THE PAST … In your best estimate, how often did the following things happen in your
medical office OVER THE PAST … (Item E1*)
46% 23.11% 0% 17% 30% 45% 63% 75% 100%
They overlook patient care mistakes that happen
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/understand/scisafetynotes.docx
September 04, 2012 - 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? … and patient procedures), and create a communication plan to address any identified issues that may happen