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Total Results: 1,577 records

Showing results for "happen".

61. 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. 

62. 155-Performing-Premortem-Project-Assessment (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/155-performing-premortem-project-assessment.docx
    October 01, 2024 - What if there was a magic telescope that could look into the future and let you see what is going to happen … Assessment can ensure that everyone is aware of the potential failure points and, if something does start to happen

63. 109-Performing-Premortem-Project-Assessment-Fg (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/109-performing-premortem-project-assessment-fg.docx
    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 … Assessment can ensure that everyone is aware of the potential failure points and, if something does start to happen

64. 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

65. PowerPoint Presentation: Learn From Defects Through Sensemaking
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects.pptx
    December 01, 2017 - Anything you do not want to happen again. … SAY: A defect is anything you do not want to have happen again or ever have happen, even if it hasn’t … From view of person involved Why did it happen? … 20 Why Did It Happen? … From view of person involved Why did it happen?

66. Learn From Defects in Care of Mechanically Ventilated Patients: Facilitator Guide | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/mvp/modules/cusp/learn-from-defects-fac-guide.html
    February 01, 2017 - Say: A defect is anything you do not want to happen again or to ever happen. … Why did it happen? How will you reduce the risk of the defect happening again? … Slide 20: Why Did It Happen? … Slide 21: Why Did It Happen? Say: Make the "whys" visual. … Slide 22: Why Did It Happen?

67. 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

68. Sensemaking and Learn From Defects for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-fac-guide.html
    July 01, 2023 - Why did it happen? What will you do to reduce risk? … The consequent event is described in terms of the event's consequences: Harm that did happen. … Harm that did not happen—No-harm event. Event did not reach the patient—Near-miss event. … Why did it happen? Step 1. Visualize the factors that led to the event. Step 2. … Defects are clinical or operational events that you do not want to happen again.

69. Hospital Survey on Patient Safety Culture: Background and Information for Translators (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/resources/infotranshsops.pdf
    September 01, 2009 - 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. … worded) (More about this item: It is because of good luck or good fortune that more mistakes do not happen … 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.

70. How CAHPS Surveys Measure Patient Experience | Agency for Healthcare Research and Quality
    www.ahrq.gov/cahps/news-and-events/podcasts/measure-patient-experience-podcast.html
    March 01, 2017 - we talk about patient experience, we're talking about specific aspects of health care delivery that happen … experience in a CAHPS survey, we're trying to find out from patients whether something that should happen … in a health care setting—something such as clear communication with a provider—actually did happen or

71. PowerPoint Presentation: Learn From Defects for Sustainability
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_learn_from_defects.pptx
    December 01, 2017 - Anything you do not want to happen again. … A defect is anything you do not want to happen or have happen again. … From view of people involved Why did it happen? … Why Did It Happen? … ASK: Why did it happen?

72. Identify Defects Through Sensemaking | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/cusp/modules/identify/identify.html
    December 01, 2012 - Why Did It Happen? Slide 24. What Will You Do To Reduce the Risk of Recurrence? Slide 25. … Why did it happen? What will you do to reduce the risk of recurrence? … (vignette still) Click to play Return to Contents   Slide 23: Why Did It Happen? … Defects or failures are clinical or operational events that you do not want to happen again.

73. Understanding CAHPS® Surveys: A Primer for New Users (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-patient-experience-fry-webinar.pdf
    January 01, 2014 - Satisfaction • Patient Experience  Focus on patient reports  Whether something that should happen … actually did happen, and how often it happened  Frequency scales  Objective assessment • Patient

74. 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

75. Accessible Facilitator Guide: Learn From Defects for Sustainability (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_learn_from_defects_facnotes.docx
    December 01, 2017 - The same problem, though addressed for that one moment in time, could easily happen again. … SAY: Unless you fix the system and proactively prevent the defect from happening again, it will happen … A defect is anything you do not want to happen or happen again. … Slide 11 Why Did It Happen? ASK: Why did it happen?

76. Sustainability: Learning From Defects: Facilitator Notes | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/surgery/modules/sustainability/learn-from-defects-fac-notes.html
    December 01, 2017 - The same problem, though addressed for that one moment in time, could easily happen again. … Say: Unless you fix the system and proactively prevent the defect from happening again, it will happen … A defect is anything you do not want to happen or happen again. … Slide 12: Why Did It Happen? Ask: Why did it happen?

77. CLABSI and CAUTI Prevention Modules | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/clabsi-cauti-icu/implement/prevention-modules.html
    April 01, 2022 - Tier 1 interventions are actions that should happen with every patient, and Tier 2 interventions are

78. Staff Safety Assessment
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/identify/sensemaking.pptx
    January 01, 2006 - Why did it happen? 3. What will you do to reduce the risk of recurrence? 4. … 22 Why Did It Happen? 23 What Will You Do To Reduce the Risk of Recurrence? … several common themes Defects or failures are clinical or operational events that you do not want to happen

79. Learn From Defects Tool Worksheet: Catheter-Associated Urinary Tract Infection (CAUTI) (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cauti-learning-from-defects-revised.pdf
    April 01, 2022 - No Yes No Why did the CAUTI happen? What factors contributed?

80. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/learn-from-defects-facguide.docx
    January 01, 2017 - SAY: A defect is anything you do not want to happen again or to ever happen. … Why did it happen? 3. How will you reduce the risk of the defect happening again? 4. … Slide 14 Why Did It Happen? SAY: Next, move on to why the defect happened. … Slide 19 Why Did It Happen? … Slide 20 Why Did It Happen? SAY: Make the “whys” visual.