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Showing results for "happen".

21. Defects (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module2/defects.docx
    March 01, 2017 - the types of systems that contributed to the defect (an event or situation that you do not want to happen … Why did it happen?

22. Learning-From-Antibiotic-Adverse (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/learning-from-antibiotic-adverse.docx
    June 01, 2021 - Events An antibiotic-associated adverse event is any event or situation that you would not want to happen … (Why did it happen?) Step 3. … (Why did it happen?) Factors Moment 1: Does the resident have symptoms that suggest an infection?

23. Module 2: Example (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/visual/visual-mgmt-pdsa-form.docx
    May 01, 2017 - reviewed during huddle; if huddle is not scheduled regularly yet, let all relevant staff know huddle will happen … Predict what will happen when the test is carried out (e.g., if we do “x,” “y” will happen) Measures … When to be done Where to be done Predict what will happen … when the test is carried out (i.e., if we do “x,” “y” will happen) Measures to compare prediction

24. Mo-Survey-English-2021 (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/MO-Survey-English-2021.docx
    January 01, 2021 - SECTION A: List of Patient Safety and Quality Issues The following items describe things that can happen … In your best estimate, how often did the following things happen in your medical office OVER THE PAST … They overlook patient care mistakes that happen over and over 1 2 3 4 5 9 3. … Mistakes happen more than they should in this office 1 2 3 4 5 9 4. … This office is good at changing office processes to make sure the same problems don’t happen again

25. SOPS Medical Office Survey (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/medical-office-survey-english-2023.docx
    January 01, 2023 - SECTION A: List of Patient Safety and Quality Issues The following items describe things that can happen … In your best estimate, how often did the following things happen in your medical office OVER THE PAST … They overlook patient care mistakes that happen over and over 1 2 3 4 5 9 3. … Mistakes happen more than they should in this office 1 2 3 4 5 9 4. … This office is good at changing office processes to make sure the same problems don’t happen again

26. Medical Office Survey on Patient Safety Culture (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/MO-Survey-English-2021.pdf
    January 01, 2021 - SECTION A: List of Patient Safety and Quality Issues The following items describe things that can happen … In your best estimate, how often did the following things happen in your medical office OVER THE PAST … They overlook patient care mistakes that happen over and over .............................. … Mistakes happen more than they should in this office ............................................. … This office is good at changing office processes to make sure the same problems don’t happen again

27. AHRQ Safety Program for MRSA Prevention
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/002-cusp-learning-defects.pptx
    October 01, 2024 - Defects: Clinical or operational events or situations that you do not want to happen again Examples of … Why did it happen?  … Safety Program for MRSA Prevention | ICU & Non-ICU Learning From Defects 11 Question 2 Why Did It Happen … AHRQ Safety Program for MRSA Prevention | ICU & Non-ICU Learning From Defects LFD Process: Why Did It Happen … Why did it happen? How will you reduce the likelihood of this defect happening again?

28. Plan-Do-Study-Act Worksheet (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/pdsa-worksheet.pdf
    August 20, 2018 - ______________________________________________________________________ What do you predict will happen … What do you need to do to get ready: How will you evaluate how it went: What do you predict will happen

29. Learning From Defects Through Sensemaking: Slide Presentation | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-slides.html
    December 01, 2017 - Anything you do not want to happen again. … (From view of person involved) Why did it happen? … Slide 15: Why Did It Happen? … Slide 16: Why Did It Happen? … Slide 22: Why Did It Happen?

30. AHRQ_Brand_NameOnly (xls file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/sustainability/sustainability-assesment-tool.xlsx
    March 01, 2017 - Who will make this happen? How do I know to move to next step? … [Be specific and include important steps to make the idea/activity happen.] … I need to make this happen? … Who will make this happen? [Be specific for each task.] When will this happen? … What other information do I need to make this happen?

31. Proposed Order of Sections in Survey (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/mosurvey-form.doc
    June 09, 2016 - SECTION A: List of Patient Safety and Quality Issues The following items describe things that can happen … In your best estimate, how often did the following things happen in your medical office OVER THE PAST … They overlook patient care mistakes that happen over and over (1 (2 (3 (4 (5 (9 3. … Mistakes happen more than they should in this office (1 (2 (3 (4 (5 (9 4. … This office is good at changing office processes to make sure the same problems don’t happen again

32. Medical Office Survey on Patient Safety (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/mosurvey-form.pdf
    June 06, 2018 - SECTION A: List of Patient Safety and Quality Issues The following items describe things that can happen … In your best estimate, how often did the following things happen in your medical office OVER THE PAST … They overlook patient care mistakes that happen over and over .................................. … Mistakes happen more than they should in this office ............................................. … This office is good at changing office processes to make sure the same problems don’t happen again

33. Survey on Patient Safety (facility version) (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.doc
    November 15, 2019 - It is just by chance that more serious mistakes don’t happen around here (1 (2 (3 (4 (5 11. … My supervisor/manager overlooks patient safety problems that happen over and over (1 (2 (3 (4 ( … 5 SECTION C: Communications How often do the following things happen in your work area/unit? … We are informed about errors that happen in this unit (1 (2 (3 (4 (5 4. … (5 SECTION D: Frequency of Events Reported In your work area/unit, when the following mistakes happen

34. PowerPoint Presentation
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/090-decolonization-implementation.pptx
    April 01, 2025 - for MRSA Prevention | Surgical Services Decolonization Implementation 6 Where Does Decolonization Happen … Why did it happen? How to reduce the likelihood of this defect from happening again? … Increase in SSIs in the cardiac surgery population, with most being MRSA infections Why Did It Happen … Mupirocin compliance at 90% Why Did It Happen? … month revealed that not all patients were being asked about compliance with CHG bathing Why Did It Happen

35. Survey on Patient Safety (facility version) (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.pdf
    November 18, 2019 - It is just by chance that more serious mistakes don’t happen around here .......................... … My supervisor/manager overlooks patient safety problems that happen over and over .................. … 1 2 3 4 5 3 SECTION C: Communications How often do the following things happen … We are informed about errors that happen in this unit .............................. 1 2 3 4 5 … SECTION D: Frequency of Events Reported In your work area/unit, when the following mistakes happen

36. 023-Ss-Cusp-Learning-From-Defects-Fg (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/023-ss-cusp-learning-from-defects-fg.docx
    April 01, 2025 - Another way to describe a defect is Anything that you do not want to happen again. … Why did it happen? 3. How will you reduce the likelihood of this defect happening again? 4. … Slide 11 Question Two—Why Did It Happen? … Slide 12 Learning From Defects Process: Why Did It Happen? … · Why did it happen? · How will you reduce the likelihood of this defect happening again?

37. Learn From Defects in Care of Mechanically Ventilated Patients: Slide Presentation | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/mvp/modules/cusp/learn-from-defects-slides.html
    February 01, 2017 - Why did it happen? How will you reduce the risk of it happening again? … Slide 15: Why Did It Happen? … Slide 20: Why Did It Happen? Try to go deeper as you identify contributing factors. … Slide 21: Why Did It Happen? … Slide 22: Why Did It Happen? What about the people side of the defect?

38. Presentation: Program Overview
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/learn-from-defects-slides.pptx
    January 01, 2017 - A defect is any clinical or operational event or situation that you would not want to happen again. … From the view of the person involved Why did it happen? … Learn From Defects ‹#› AHRQ Safety Program for Mechanically Ventilated Patients 14 Why Did It Happen … Why Did It Happen? … Why Did It Happen?

39. 004-Cusp-Learning-From-Defects (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/004-cusp-learning-from-defects.docx
    October 01, 2024 - Why did it happen? 3. How will you reduce the likelihood of this defect happening again? 4. … Slide 11 Why Did It Happen? … Slide 12 LFD Process: Why Did It Happen? … Defects are clinical or operational events that you do not want to happen again. … · Why did it happen? · How will you reduce the likelihood of this defect happening again?

40. Learning From Defects | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/mrsa-prevention/toolkit/learning-from-defects.html
    October 01, 2024 - CUSP and MRSA Prevention A defect is broadly defined as "Anything you do not want to have happen … Why did it happen? How will you reduce the likelihood of this defect from happening again?