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Showing results for "happen".

41. 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?

42. Appendix A. Action Plan Tool for Project Sustainability | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/cauti-tools/guides/sustainability-guideapa.html
    October 01, 2015 - Plan for Sustainability Need or Interest Idea or Activity Tools To Use How Will This Happen … Who Should Make This Happen? When Will This Happen? … What Other Information Do I Need To Make This Happen?

43. SOPS® Nursing Home Survey Items and Composite Measures (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursing-home-survey-items-composite-english.pdf
    September 01, 2024 - Sometimes, Most of the time, Always, Does Not Apply or Don’t Know) How often do the following things happen … Sometimes, Most of the time, Always, Does Not Apply or Don’t Know) How often do the following things happen … Sometimes, Most of the time, Always, Does Not Apply or Don’t Know) How often do the following things happen … This nursing home lets the same mistakes happen again and again. (negatively worded) D4.

44. Diagnostic Safety and Quality | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/index.html
    January 01, 2007 - Diagnostic Safety and Quality Learn about AHRQ's research to better understand how diagnostic errors happen … AHRQ funds research to better understand how diagnostic errors happen and what can be done to prevent

45. 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?

46. Appendix B19: Handout for Inservice #1, Why Falls Happen, Spanish | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/fallspxmanapb19.html
    December 01, 2017 - Quality Improvement Initiative for Nursing Facilities Appendix B19: Handout for Inservice #1, Why Falls Happen

47. Premortem Assessment | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/mrsa-prevention/surgery/premortem-assessment.html
    April 01, 2025 - What if there was a magic telescope that could look into the future and let you see what is going to happen

48. CLABSI Learning From Defects Tool (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/clabsi-learning-from-defects_revised.docx
    April 01, 2022 - ) Hemodialysis Other: _____________________ Why did the CLABSI happen

49. AHRQ Hospital Survey on Patient Safety Culture: Items and Dimensions (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hsops-items-composites.pdf
    June 02, 2025 - My supervisor/manager overlooks patient safety problems that happen over and over. … It is just by chance that more serious mistakes don't happen around here. (negatively worded) A17. … We are informed about errors that happen in this unit. C5.

50. Learn from Defects Tool | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/cusp/toolkit/learn-defects.html
    December 01, 2012 - A defect is any clinical or operational event or situation that you would not want to have happen again … Why did it happen? Below is a framework to help you review and evaluate your case.

51. Aspirin, Heart Disease, and Stroke Pamphlet: American Stroke Association | Agency for Healthcare Research and Quality
    www.ahrq.gov/evidencenow/heart-health/aspirin/stroke.html
    September 01, 2018 - Resource description: This patient education booklet explains how heart attack and stroke happen, and

52. Learn From Defects Tool (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/tools/applying-cusp/learn_from_defects.docx
    December 01, 2017 - Why did it happen? … Why did it happen? Investigate your care delivery system. … Why did it happen? … Why did it happen? … Why did it happen?

53. Communication and Optimal Resolution (CANDOR) Toolkit | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules.html
    August 01, 2022 - Module 7: Resolution Module 8: Organizational Learning and Sustainability “We realize mistakes happen … Harms such as hospital-acquired infections or medication errors can happen during any stage of care.

54. CAUTI Learning From Defects Tool (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cauti-learning-from-defects-revised.docx
    April 01, 2022 - (Circle): Yes No Why did the CAUTI happen?

55. Chapter 1. Background | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/chapter1.html
    August 01, 2022 - What caused the patient safety event to happen? Where did the patient safety event happen?

56. Sustainability: Learning From Defects: Slide Presentation | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/surgery/modules/sustainability/learn-from-defects-slides.html
    December 01, 2017 - Slide 6: What Is a Defect Anything you do not want to happen again. … (From view of person involved) Why did it happen? … Slide 12: Why Did It Happen? Critical to include adaptive teamwork concerns.

57. Learning From Defects Through Sensemaking: Facilitator Notes | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-fac-notes.html
    December 01, 2017 - Say: A defect is anything you do not want to have happen again or ever have happen, even if it hasn … Why did it happen? How will you reduce the risk of it happening again? … Slide 21: Why Did It Happen? Ask: Why did the defect occur? … Slide 22: Why Did It Happen? Say: Make the whys visual. … Slide 23: Why Did It Happen? Say: Think about the culture.

58. Facilitator Guide: Learning From Defects Through Sensemaking (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects_facnotes.docx
    December 01, 2017 - Does the same fix happen for all patients, all caregivers, and all shifts? … SAY: A defect is anything you do not want to have happen again or ever have happen, even if it hasn’t … Slide 20 Why Did It Happen? ASK: Why did the defect occur? … Slide 21 Why Did It Happen? SAY: Make the whys visual. … Slide 22 Why Did It Happen? SAY: Think about the culture.

59. Learn From Defects Tool Worksheet: Central Line-Assoiated Bloodstsream Infection (CLABSI) (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/clabsi-learning-from-defects-revised.pdf
    April 01, 2022 - administration Total parenteral nutrition (TPN) Hemodialysis Other: _____________________ Why did the CLABSI happen

60. What We Planned, What Happened, and What We Learned | Agency for Healthcare Research and Quality
    www.ahrq.gov/takeheart/assessing/slide-presentation/index.html
    August 01, 2023 - What We Planned, What Happened, and What We Learned TAKEheart: AHRQ's Initiative to Increase Patient Participation in Cardiac Rehabilitation This PowerPoint Presentation explores what the AHRQ TAKEheart team planned from this project, what happened, and what was learned. It was presented by Michael Harrison…