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www.ahrq.gov/news/newsroom/case-studies/201534.html
December 01, 2015 - impact it is having is that patients come in with an expectation and better sense of what is going to happen
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/webinar-012220-fry.pdf
June 02, 2025 - Understanding CAHPS® Surveys: A Primer for New Users - Fry
WHAT IS PATIENT EXPERIENCE
AND HOW DOES CAHPS
MEASURE IT?
Stephanie Fry
Senior Study Director
Westat
What is Patient Experience?
Patient experience encompasses the range of interactions that
patients have with the health care system, including:
Co…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/2020_MOSOPS_Part_II_508.pdf
January 01, 2020 - They overlook patient care mistakes that happen over and over. … Mistakes happen more than they should in this office. … They overlook patient care mistakes that happen over
and over. … Mistakes happen more than they should in this office. … They overlook patient care mistakes that happen over
and over.
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/2022-MOSOPS-Database-Report-Part-II-508.pdf
January 01, 2022 - (Item F2) 85% 89% 87% 85% 79% 80% 74%
% Disagree/Strongly Disagree
Mistakes happen more than they … (Item E1*) 46% 34%
They overlook patient care mistakes that happen over and over. … (Item E1*) 46% 44% 46% 50%
They overlook patient care mistakes that happen over and over. … (Item E1*) 42% 45% 44% 31%
They overlook patient care mistakes that happen over and over. … (Item E1*) 52% 43% 42% 39% 41%
They overlook patient care mistakes that happen over and over.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/navigating-hierarchy-transcript.doc
December 10, 2013 - and chatted for a little while with the staff, and they said, “Well, we can’t really get anything to happen … towards inter-professional practice and inter-professional education, so we’re starting to see that trend happen … If it continues to happen, then you’ve got to figure out a way to escalate that to the right place, and … These things happen all the time, when that interdepartmental hierarchy sometimes happens, where you
-
www.ahrq.gov/hai/cauti-tools/archived-webinars/engaging-nurse-physician-patient-transcript.html
December 01, 2017 - It doesn't happen to be just a day issue. So really, the expectation is every shift is responsible. … need it, and say, "Why don't we think about taking it out, what would be the worst thing that could happen … The definition of a defect being that it is anything that anyone does not want to happen again. … Why did it happen? It focuses on contributing factors, and it lists examples there of factors. … and in this case it was the hand-off process, or a double check process, to ensure that this doesn't happen
-
www.ahrq.gov/hai/cauti-tools/archived-webinars/navigating-hierarchy-transcript.html
December 01, 2017 - and chatted for a little while with the staff, and they said, “Well, we can't really get anything to happen … towards inter-professional practice and inter-professional education, so we're starting to see that trend happen … If it continues to happen, then you've got to figure out a way to escalate that to the right place, and … These things happen all the time, when that interdepartmental hierarchy sometimes happens, where you
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/020-ss-periop-infection-prevention.pptx
April 01, 2025 - Why did it happen?
How to reduce the likelihood of this defect from happening again? … MRSA Prevention| Surgical Services
Perioperative Infection Prevention
32
Case Example: Why Did It Happen
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-surgery/020-perioperative-infection-prevention-strategies-slides.pptx
April 01, 2025 - Why did it happen?
How to reduce the likelihood of this defect from happening again? … MRSA Prevention| Surgical Services
Perioperative Infection Prevention
32
Case Example: Why Did It Happen
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/esrd/creating-safety-culture/cultureofsafety_hemodialysis.pptx
September 03, 2014 - 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?
What will we do to reduce the risk of recurrence? … Why did it happen?
Step 1. Visualize the factors that led to the event.
Step 2. … Why did it happen?
3. What will you do to reduce the risk of recurrence?
4.
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www.ahrq.gov/hai/tools/mrsa-prevention/surgery/cusp-mrsa-prevention.html
April 01, 2025 - Assessment The Premortem Tool is a proactive way to anticipate risks and failures before they actually happen
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mod2concl.html
October 01, 2014 - Module 2: Communicating Change in a Resident's Condition
Conclusion
Previous Page Next Page
Table of Contents
Module 2: Communicating Change in a Resident's Condition
Learning and Performance Objectives
Session 1
Session 2
Conclusion
Additional Tools and Resources
Appendix. Example of th…
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/DESC-technique.pdf
June 01, 2021 - DESC Technique for Conflict With Residents and Families
DESC Script. Johns Hopkins Medicine, Armstrong Institute. Kentucky
Hospital Improvement Innovation Network. KY. July 2012.
http://www.k-
hen.com/Portals/16/Documents/PSCTCommunicationsLab.pdf.
Accessed Jun 19, 2017.
Describe the specific situation.
Expre…
-
www.ahrq.gov/diagnostic-safety/resources/issue-briefs/leadership-3.html
June 01, 2021 - people need feedback on the organization’s progress toward those goals and to understand what will happen
-
www.ahrq.gov/sites/default/files/publications/files/ltcmodule3.pdf
June 01, 2012 - They have learned how to avoid those situations and, when they
do happen, to fix them as well as they … A situation in
which a care provider’s actions are not well-intended may happen; that
person may have … Sometimes, there is a situation that can
be called “an accident waiting to happen.” … o Fixing “accidents waiting to happen.” … Not having a falls assessment for a resident is like allowing an “accident
waiting to happen” to occur
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module6/module6-care-for-caregiver.pptx
May 01, 2011 - The second-victim is often fearful at this point about what is going to happen next and whether or not … clinical staff involved in the event, notify clinical staff involved in the event what is going to happen
-
www.ahrq.gov/teamstepps-program/curriculum/communication/overview/index.html
June 01, 2023 - ownership
Situation Awareness & Contingency Planning
Know what’s going on
Plan for what might happen
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/grandrounds/mod01-grand-rounds-slides.pdf
April 01, 2016 - physician, and/or care provider to be
fully transparent when an error occurs, but often this doesn’t happen … ■ It is important to understand that communication doesn’t happen just
once and then you are done
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/part-ii-sops-asc-database-report.pdf
January 01, 2020 - We are good at changing processes to make sure the same patient
safety problems don’t happen again. … Staff are told about patient safety problems that happen in this facility. … Staff are told about patient safety problems that happen in this
facility. … Staff are told about patient safety problems that
happen in this facility. … Staff are told about patient safety problems that happen in this
facility.
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/Part-II-SOPS-ASC-DatabaseReport.pdf
December 01, 2021 - 94% 92% 91%
We are good at changing processes to make sure the same patient safety
problems don’t happen … (Item C4) 88% 85% 84% 82%
Staff are told about patient safety problems that happen in this facility … (Item C4) 82% 82% 85% 85%
Staff are told about patient safety problems that happen in this facility … (Item C4) 87% 97% 74% 94% 94% 83% 78% 76% 76%
Staff are told about patient safety problems that
happen … (Item C4) 92% 83% 79% 91%
Staff are told about patient safety problems that happen in this
facility