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Showing results for "happen".

61. 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.

62. 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.pdf
    April 01, 2022 - administration Total parenteral nutrition (TPN) Hemodialysis Other: _____________________ Why did the CLABSI happen

63. 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

64. 20 Tips To Help Prevent Medical Errors: Patient Fact Sheet | Agency for Healthcare Research and Quality
    www.ahrq.gov/questions/resources/20-tips.html
    November 01, 2020 - They can happen during even the most routine tasks, such as when a hospital patient on a salt-free diet … But errors also happen when doctors * and patients have problems communicating. … If you know what might happen, you will be better prepared if it does or if something unexpected happens

65. 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.

66. SOPS Nursing Home Survey Items and Composites (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/nursing-home/nhguide/sops-nursing-home-items.pdf
    January 01, 2000 - 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.

67. SOPS Nursing Home Survey Items and Composite Measures (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/sops-nurse-home-items-06-16-21.pdf
    January 01, 2000 - 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.

68. 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

69. 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

70. 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?

71. 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?

72. 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.

73. 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?

74. 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?

75. 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
    February 16, 2021 - 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.

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. 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?

78. 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.pdf
    April 01, 2022 - No Yes No Why did the CAUTI happen? What factors contributed?

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. Teach-Back Questions for Informed Consent | Agency for Healthcare Research and Quality
    www.ahrq.gov/health-literacy/improve/precautions/tool5b.html
    March 01, 2024 - "Just to make sure that I explained things well, can you tell me in your own words what will happen if … Can you tell me in your own words what might happen?"