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  1. www.ahrq.gov/hai/tools/mvp/modules/cusp/action-plan-trip-fac-guide.html
    February 01, 2017 - State your objectives and make a prediction about what will happen and why. … Ask: What did you predict would happen? What actually happened? What did you learn?
  2. www.ahrq.gov/funding/process/grant-app-basics/hsubjects.html
    August 01, 2018 - This may happen for various reasons, some related to the claims about the research protocol (e.g., for
  3. www.ahrq.gov/sites/default/files/wysiwyg/hai/cauti-tools/cauti-icu/preventing-cauti-icu-setting-module_2-speaker-notes.docx
    September 01, 2015 - In this scenario, the transporter didn’t understand what might happen because of wrong bag placement
  4. www.ahrq.gov/hai/cauti-tools/archived-webinars/integrating-teamwork-tools-cusp-efforts-transcript.html
    December 01, 2017 - It helps to anticipate what may come, helps you be prepared if the unexpected were to happen. … If you have a culture where this s encouraged, hopefully that won't happen. … I think many of you will be able to relate to some of these issues that happen here in this scenario.
  5. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/integrating-teamwork-tools-into-cusp-efforts-transcript.docx
    April 07, 2015 - It helps to anticipate what may come, helps you be prepared if the unexpected were to happen. … If you have a culture where this is encouraged, hopefully that won't happen. … I think many of you will be able to relate to some of these issues that happen here in this scenario.
  6. www.ahrq.gov/sites/default/files/wysiwyg/pqmp/toolkits/vchip-strategies-for-kdd.pdf
    February 01, 2015 - One planned visit can happen during the Health Supervision Visit (HSV).
  7. www.ahrq.gov/teamstepps-program/curriculum/team/implement/teach-change.html
    February 01, 2024 - groups, and individuals in the organization who must feel the need for change for team training to happen … Explain that the third phase in implementing change is making it happen.
  8. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruprev/spectorhudak.ppt
    December 01, 2013 - Using HIT for Prevention in Nursing Homes Pressure ulcers, falls, and preventable hospitalizations happen
  9. www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/care/resources/ontime/pruprev/spectorhudaktxt.html
    December 01, 2017 - HIT for Prevention in Nursing Homes   Pressure ulcers, falls, and preventable hospitalizations happen
  10. www.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/chapter4.html
    August 01, 2022 - What caused the patient safety event to happen? Where did the patient safety event happen?
  11. www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/antibiotic-patient-safety-facilitator-guide.docx
    June 01, 2021 - Why did it happen? How can we reduce the risk of this happening again?
  12. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module4/module-4-slides.pptx
    March 01, 2017 - N Next—What will happen next? Anticipated changes? What is the plan? … frontline care providers is to help and care for residents without harming them, but adverse events happen
  13. www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/teamwork-ptsafety-norms-slides.pdf
    August 01, 2025 - • Anything that you do not want to happen again Errors Provide Useful Information • We can learn … From view of person involved Why did it happen? How will you reduce it happening again?
  14. www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/2018hospitalsopsreport-rev0921.pdf
    March 01, 2018 - (B3R) 79% My supv/mgr overlooks patient safety problems that happen over and over. … (C1) 61% We are informed about errors that happen in this unit. … Overall Perceptions of Patient Safety It is just by chance that more serious mistakes don’t happen … My supv/mgr overlooks patient safety problems that happen over and over. 80% 79% 1% 66% -26% 4% - … We are informed about errors that happen in this unit. 70% 69% 1% 28% -38% 5% -5% C5 3.
  15. www.ahrq.gov/sites/default/files/2024-01/hall1-report.pdf
    January 01, 2024 - The probability rating was also determined, and points were assigned: frequent – may happen several … times in one shift or 1 day (4 points); occasional – may happen several times in 1 week to 1 month ( … 3 points); uncommon – may happen sometime in 1 to 6 months (2 points); or remote – may happen sometime
  16. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/025-ss-why-choose-cusp-fg.docx
    April 01, 2025 - a defect is defined as “any clinical or operational event or situation that you do not want to have happen … Our goal is to fix the systems in which we operate, so that errors do not happen again.
  17. www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/safe-electronic-tool.html
    July 01, 2023 - plan is through briefings and team management, being aware of what is going on and what is likely to happen … provide timely, clear information to patient and family to explain what is happening, what needs to happen
  18. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/booklets/hip-fracture-booklet.pdf
    November 01, 2023 - And things may happen very fast.
  19. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/educational-bundles/communication-and-teamwork/communication-strategies.pptx
    September 01, 2016 - was at risk Communication ׀ 13 AHRQ SAFETY PROGRAM FOR LONG-TERM CARE: HAIs/CAUTI What could've happen … What if it doesn't happen? There may be times when an initial assertion is ignored.
  20. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/actionplan-trip-facguide.docx
    January 01, 2017 - State your objectives and make a prediction about what will happen and why. … ASK: What did you predict would happen? What actually happened? What did you learn?

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