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Showing results for "happen".

41. 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?

42. 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?

43. 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

44. 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.

45. 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.

46. 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

47. 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?

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. Appendix B13: Pre and Posttests for Inservice #1, Why Falls Happen | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb7.html
    December 01, 2017 - Improvement Initiative for Nursing Facilities Appendix B13: Pre and Posttests for Inservice #1, Why Falls Happen

50. 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.

51. 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?

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. 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?

54. 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.

55. 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.

56. 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.

57. Hospital Survey Version 2.0: Background and Information for Translators | Agency for Healthcare Research and Quality
    www.ahrq.gov/sops/international/hospital/translators-version-2.html
    October 01, 2024 - (negatively worded) More about this item: When patient safety problems happen, this unit does not … do anything to ensure the problem does not happen again. 4. … negatively worded) More about this item: Staff feel like they are unfairly blamed when mistakes happen … We are informed about errors that happen in this unit. C2.  … When errors happen in this unit, we discuss ways to prevent them from happening again. C3. 

58. 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

59. 130-Ss-Swiss-Cheese-Fg (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/130-ss-swiss-cheese-fg.docx
    April 01, 2025 - SAY: A defect is broadly defined as “Anything you do not want to happen again.” … failures are the “holes in the system”—the weaknesses that create conditions for an active failure to happen … These outcomes are “defects”—the events that the team does not want to happen again. … When errors happen, attention is often focused on individual provider behavior or actions. … When defects happen, it is essential to use new lenses to identify systems in play and be vigilant in

60. Hospital SOPS Translation Information | Agency for Healthcare Research and Quality
    www.ahrq.gov/sops/international/hospital/translators.html
    October 01, 2014 - 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. … In other words, the reason mistakes do not happen more often is good luck, not because procedures or … We are informed about errors that happen in this unit. C5. … worded) ( More about this item: Shift changes cause problems for patients in this hospital—problems happen