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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/talkingquality/translate/compare/choose/standard.html
January 01, 2023 - These events are preventable and should never happen.”
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module3/video-transcript-spanish.docx
June 02, 2025 - Unfortunately, things like this happen. … I hope that doesn´t happen to me. What should I do?
¿En serio? Espero que no me pase lo mismo. … It was an honest mistake, which won´t happen again. I´m sorry.
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/asc-survey-english.docx
June 02, 2025 - Staff are told about patient safety problems that happen in this facility ........................... … We are good at changing processes to make sure
the same patient safety problems don’t happen again
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www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module4-presenters-notes.pdf
January 05, 2022 - These examples can be from actual experience or situations that you imagine
could happen. … Slide 11
could happen.
3. … • How could that happen in your setting? … • Did everything happen for a patient or patients that was intended? … These examples can be
from actual experience or situations that you imagine could happen
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy3/Strat3_Tool_2_Nurse_Chklst_508.docx
June 02, 2025 - “What do you want to happen during the next 12 hours?”
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-slides.html
July 01, 2023 - Question 2: Why did it happen?
Question 3: What will you do to reduce the risk of reoccurrence? … Defects or failures are clinical or operational events that you do not want to happen again.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/understand/scisafety.pptx
March 01, 2009 - deaths from central line-associated blood stream infections per year8
4
4
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/hai/tools/surgery/modules/on-boarding/science-of-safety-fac-notes.html
December 01, 2017 - Slide 6: How Do These Errors Happen? … Say:
Errors happen because people are fallible. … a powerful exercise in which teams evaluate their processes to identify gaps that allow mistakes to happen … Simply put, a defect is any clinical or operational event or situation that you would not want to happen
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/05-sops-teamstepps-webcast-mazur.pdf
April 30, 2022 - Communication; 1 unit data only)
Communication about error 82 +15
We are informed about errors that happen … in this unit. 80 +15
When errors happen in this unit, we discuss ways to
prevent them from happening
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www.ahrq.gov/hai/cusp/toolkit/content-calls/business-case.html
April 01, 2013 - set the stage with this one, that if you do the improvements in quality and patient safety, what can happen … It isn’t going to happen. … Let’s go to slide number 25 and take a look at what does happen to hospital throughput. … What would happen if you put a sign up in your hospital that said, 25 minutes since our last hospital … You’re spending more, but what’s going to happen is you’ll stop the spread of infection from staff to
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www.ahrq.gov/hai/cusp/modules/identify/alt-text.html
March 01, 2013 - Why did it happen?
What will you do to reduce the risk of recurrence? … (vignette still)
Click to play
Video icon
Slide 23
Why Did It Happen? … several common themes
Defects or failures are clinical or operational events that you do not want to happen
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/science-of-safety-slides.pptx
January 01, 2017 - Science of Safety ‹#›
AHRQ Safety Program for Mechanically Ventilated Patients
4
Errors Happen Because … individual doctors and nurses
Health care systems are rarely designed to catch mistakes before they happen
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/2020_MOSOPS_Part_I-rev0921.pdf
January 01, 2020 - (F2)
Mistakes happen more than they should
in this office . … (E1R)
They overlook patient care mistakes that
happen over and over. … 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. … They overlook patient care mistakes that happen over
and over.
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/nyp-webinar-grob-narrative-elicitation-protocol.pdf
June 02, 2025 - Implementing the New CAHPS® Protocol for Obtaining Patient Comments About Their Care
The CAHPS Narrative Elicitation
Protocol
Rachel Grob, Ph.D.
Director of National Initiatives and Clinical Professor,
Center for Patient Partnerships
Madison, WI
www.ahrq.gov/cahps
CAHPS Narrative Elicitation Protocol
• A …
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www.ahrq.gov/cahps/surveys-guidance/item-sets/cg/suppl-narrative-items-cg-survey30-adult.html
August 01, 2021 - Supplemental Items for the CAHPS Clinician & Group Adult Survey 3.0/3.1: Narrative Comments
Population version: Adult
Learn about the CAHPS Patient Narrative Item Sets .
Placing the items in the survey:
Insert these supplemental items before the "About You" section of the survey.
Introducing the it…
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www.ahrq.gov/hai/cauti-tools/phys-championsgd/appa.html
October 01, 2015 - What do you want to happen by when?
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www.ahrq.gov/prevention/guidelines/tobacco/clinicians/presentations/2008update-full/slide70.html
October 01, 2014 - Concerns and benefits of quitting (e.g., "What might happen if you quit?").
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www.ahrq.gov/sites/default/files/wysiwyg/hai/cauti-tools/cauti-icu/preventing-cauti-icu-setting-module-3-slides.pptx
September 01, 2015 - ‹#›
AHRQ Safety Program for Reducing CAUTI in Hospitals
4
5
What Do You Think Will Happen
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/coaching/coaching-slideset.pptx
May 01, 2017 - “Can you help me understand why that didn’t happen?