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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/012-ss-decolonization-strategies.pptx
April 01, 2025 - Why did it happen?
How to reduce the likelihood of this defect from happening again? … Inconsistent use of mupirocin nasal decolonization
Inconsistent screening of patients for MRSA
Why did it happen
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/patient-narratives-webinar-quality.pdf
May 23, 2022 - The Power of Patient Stories for Improving the Patient Experience webcast - Nembhard
Using Narratives for Quality Improvement
Ingrid Nembhard, PhD, MS
Fishman Family President’s Distinguished
Associate Professor of Health Care Management
Disclosures
This work was funded by the Agency for Healthcare
Research a…
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www.ahrq.gov/hai/tools/perinatal-care/modules/teamwork/learn-from-defects-slides.html
May 01, 2017 - 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/ncepcr/tools/self-mgmt/what-script.html
February 01, 2016 - What is Self-Management Support? (Video Transcript)
Self-Management Support
For me self management support is helping the patient to play an active role in their healthcare and to become a partner with the nurse and physician team instead of the recipient of care.
Hello Ms. Mason. How are you doing today? W…
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www.ahrq.gov/sites/default/files/wysiwyg/funding/policies/informedconsent/icformseng.doc
September 03, 2009 - · You can stop answering our questions at any time and nothing will happen to you.
· You can call the … · You can stop answering our questions at any time and nothing will happen to you.
· You can call the … · You can stop answering our questions at any time and nothing will happen to you.
· You can call the … · You can stop answering our questions at any time and nothing will happen to you.
· You can call the
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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
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hsops2-pt2_transition_apx.pdf
September 01, 2019 - (C1)
We are informed about errors that happen in this
unit. … -------------------------------------- My supervisor/manager overlooks patient safety problems that happen … 2.0
Overall Perceptions of Patient Safety
It is just by chance that more serious mistakes don’t happen … (C1)
We are informed about errors
that happen in this unit. … (C3) 66% 66% 0%
+/- 3%
[-3% to 3%]
No
change
When errors happen in this unit, we
discuss ways
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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/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module3/video-transcript-spanish.docx
April 21, 2014 - 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/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/coaching/coaching-facnotes.docx
May 01, 2017 - Can you help me understand why that didn’t happen? … If something harmful to the patient can be avoided, the coach should say something and not let it happen
-
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
-
www.ahrq.gov/sites/default/files/wysiwyg/teamstepps/diagnosis-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
-
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/ncepcr/tools/obesity-kit/obtoolkit5.html
March 01, 2014 - be translatable to any community resource and any practice willing to take the extra step to make it happen
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_scienceofsafety_facnotes.docx
December 01, 2017 - Slide 5
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
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy3/Strat3_Tool_2_Nurse_Chklst_508.docx
February 10, 2011 - “What do you want to happen during the next 12 hours?”
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/officebasedcare/agenda-lesson2.pdf
November 30, 2015 - Are any of the situations observed in the video situations that could happen in your office?
-
www.ahrq.gov/funding/policies/informedconsent/icform3c.html
September 01, 2009 - You can stop answering our questions at any time and nothing will happen to you.
-
www.ahrq.gov/ncepcr/tools/pf-handbook/mod4-appendix.html
March 01, 2022 - Predict what will happen when the test is carried out
Measures to determine if prediction succeeds
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4/module4-event-reporting-investigation-analysis.pptx
September 10, 2015 - and Analysis is that managing individual performance alone does not ensure that a harm event won’t happen … focusing on individual blame.
11
System And Individual Accountability2
Module 4
12
Why did the event happen