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Showing results for "happen".

81. Learn From Defects Tool—Perioperative Setting | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/surgery/tools/applying-cusp/learn-from-defects.html
    December 01, 2017 - Why did it happen? … Why did it happen? Investigate your care delivery system. … Why did it happen? … Why did it happen? Investigate your care delivery system. … One method you can use to reduce the likelihood that a defect will happen again is to— Focus your

82. Learn-From-Defects-Facilitator-Guide (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.docx
    May 01, 2017 - Why did it happen? What will you do to reduce risk? … Skill-based failures happen when a person fails in the performance of a routine task that normally requires … The consequent event is described in terms of the event’s consequences: Harm that did happen Harm that … 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.

83. Module 5: Response and Disclosure | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/notes.html
    August 01, 2022 - Why did the event happen? … issue and redirect the conversation toward a shared goal of ensuring that a similar event does not happen

84. 089-Or-Traffic-Fg (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/089-or-traffic-fg.docx
    April 01, 2025 - Slide 14 Case Example: Why Did It Happen? SAY: The CUSP team next examined “Why did it happen?”

85. Background and Information for Translators of the AHRQ Hospital Survey on Pateint Safety Culture Version 2.0 (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospital/sops-hsops-2-translation-guidelines.pdf
    August 01, 2023 - (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.

86. PowerPoint Presentation
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/088-or-traffic.pptx
    April 01, 2025 - Why did it happen? How to reduce the likelihood of this defect happening again? … discussion focused around OR traffic Members felt that door openings during the surgical case appeared to happen … AHRQ Safety Program for MRSA Prevention | Surgical Services OR Traffic 14 Case Example: Why Did It Happen

87. Session 1 | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mod2sess1.html
    October 01, 2014 - Sometimes systems create "an accident waiting to happen." … Following up —The next step is being clear about what will happen after the message is given and received

88. Approach to Residents With Reported Penicillin Allergy (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/penicillin-allergy.pdf
    June 01, 2021 - _______________ o How soon after starting the antibiotic did the reaction happen (e.g., minutes to hours … by: Datetime: Reviewed by physician: How soon after starting the antibiotic did the reaction happen

89. The Comprehensive Unit-based Safety Program (CUSP) for MRSA Prevention | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/mrsa-prevention/toolkit/cusp.html
    October 01, 2024 - Assessment The Premortem Tool is a proactive way to anticipate risks and failures before they actually happen … Learning From Defects A "defect" is defined as "Anything that you don't want to have happen again."

90. Learndefects (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/learndefects.doc
    June 02, 2025 - 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.

91. Public Reporting of Patients' Comments with Quality Measures: How Can We Make It Work? (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/20140603_QI/3_rachel_grob.pdf
    June 02, 2025 - past 12 months) Positive experiences: 1 Question with narrative guide (what happened, how did it happen … (past 12 months) Positive experiences: 1 Question with narrative guide (what happened, how did it happen

92. An Update on the CAHPS Patient Narrative Item Sets - Martino (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-patient-narrative-martino.pdf
    June 01, 2021 - An Update on the CAHPS Patient Narrative Item Sets - Martino UPDATED NARRATIVE ITEM SETS FOR THE CAHPS CLINICIAN & GROUP SURVEY Steven Martino, PhD Overview of Narrative Item Set Development Process • Literature review and environmental scan • Drafting of narrative items • Pretesting to assess readability and …

93. 114-Mrsa-Prevention-Learning-From-Defects (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/114-mrsa-prevention-learning-from-defects.docx
    October 01, 2024 - A defect is any clinical or operational event that you would not want to happen again. … Why did it happen?

94. Understand the Science of Safety for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/understand-sci-fac-guide.html
    July 01, 2023 - Slide 4: How Can These Errors Happen? … The first step in comprehending why they happen is accepting that people are not perfect. … Why did it happen? What will we do to reduce the recurrence? How will we know it worked? … Why did it happen? How will you reduce the risk of recurrence? How will you know it worked?

95. PowerPoint Presentation
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/module5-response-disclosure-notes.pptx
    August 21, 2015 - Why did it happen? How will the organization prevent the event from happening to another patient? … Why did the event happen? … issue and redirect the conversation toward a shared goal of ensuring that a similar event does not happen

96. Sensemaking and Learn from Defects for Perinatal Safety (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.pdf
    May 01, 2017 - • Why did it happen? • What will you do to reduce risk? … • Skill-based failures happen when a Slide 4 Sensemaking and Learn From Defects for Perinatal … The consequent event is described in terms of the event’s consequences: • Harm that did happen • … 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.

97. Using Mass Media To Spread Messages About a Quality Report | Agency for Healthcare Research and Quality
    www.ahrq.gov/talkingquality/distribute/promote/multiple/using-media.html
    September 01, 2019 - Bad press can happen because the people you worked with didn’t take the time to understand your work, … While any of these misfortunes can happen, they are not reasons to avoid working with the media entirely … Bad press can happen to anyone.

98. Engage the Team and Applying CUSP in the ICU Setting Slides (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cusp-icu-notes.docx
    April 01, 2022 - As we discussed at the beginning of this presentation, staff need a clear understanding of what will happen … · Why did it happen? · How will you reduce the risk of the defect happening again? … Slide 14 In order for the CUSP team to better understand why defects happen, make the "whys" visual

99. Nursing Home Survey on Patient Safety Culture: Background and Information for Translators (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/nursing-home/resources/infotransNHSOPS.pdf
    January 01, 2010 - expect supervisors to investigate all factors, including systems reasons, to determine why mistakes 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 … 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.

100. Sensemakingnotes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/identify/sensemakingnotes.docx
     June 02, 2025 - · Why did it happen? · What will you do to reduce risk? … categorized in three main types: skill-based, rule-based, and knowledge-based. · Skill-based failures happen … 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 We then ask why … Why did it happen? · Step 1. Visualize the factors that led to the event. · Step 2.