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www.qualitymeasures.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes4.html
August 01, 2022 - and Analysis is that managing individual performance alone does not ensure that a harm event won't happen
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-3-implementation-guide.pdf
February 13, 2023 - Remember you are documenting what ACTUALLY happens – not what SHOULD happen ideally.
d. … What does happen? Who takes care of
this? Who is ultimately accountable? Where does this go?
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/huddles/huddles-component-kit.docx
May 01, 2017 - In ambulatory surgery centers (ASCs), huddles can happen once per day with each unit (e.g., the operating … Level 3: Daily huddles happen when the supervisor is not present. … What can you do to make the huddle happen every day?
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www.qualitymeasures.ahrq.gov/hai/cusp/videos/index.html
September 01, 2019 - Why Did It Happen?
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/item-sets/administering-child-hcahps-narrative-items.pdf
November 01, 2023 - Administering the CAHPS Child Hospital Narrative Item Set
Administering the CAHPS® Child Hospital
Narrative Item Set
November 2023
Introduction ..................................................................................................................... 1
Deciding Whether to Use Narrative Items .........…
-
www.qualitymeasures.ahrq.gov/health-literacy/professional-training/informed-choice/audio-script.html
September 01, 2020 - Can you tell me in your own words what might happen?” … What might happen then? … Doctor: Yes…that could unfortunately happen. … Doctor: That could happen. … How likely are they to happen?
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/mod5-comm-assessment.pdf
April 01, 2016 - stable; her heart rate, blood pressure, and oxygen level are all in normal ranges, but something did happen
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/resources/asc-survey.pdf
June 06, 2018 - Staff are told about patient safety problems that
happen in this facility ......................... … We are good at changing processes to make sure
the same patient safety problems don’t happen again.
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www.qualitymeasures.ahrq.gov/teamstepps/simulation/simulationslides/simslides.html
June 01, 2019 - Processes answer the question "Why did it happen?"
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/podcasts/Teamwork_in_QI_2012_02_01_Transcript.pdf
January 01, 2012 - Marjie Harbrecht
So really as I was saying before, this has to happen at every level. … So it has to happen in the practice level where
the team within the practices are really working well … It also has to happen with patients and their families. … healthy and prevent a lot of the things that we see now that really are avoidable and
don’t need to happen
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallpxtoolkit/fallpxtool2c.docx
January 28, 2013 - used to describe key processes in your organization where fall prevention activities could or should happen
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/job-aid-5-whys.pdf
May 17, 2021 - Ask "Why does this happen?" to stimulate brainstorming.
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www.qualitymeasures.ahrq.gov/ncepcr/tools/self-mgmt/what-script.html
February 01, 2016 - Skip to main content
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www.qualitymeasures.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
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cusp-icu-slides.pptx
April 01, 2022 - From the view of the person involved
Why did it happen?
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/pf-engagement-facilitator-guide.pdf
May 01, 2017 - Medical providers are committed to caring for
their patients; however, adverse events can
happen.
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-webinar-jan-2017-schlesinger.pdf
January 01, 2017 - CAHPS Elicitation Protocol Webcast
Development and Testing of
the CAHPS Elicitation Protocol
Mark Schlesinger
Yale School of Public Health
www.ahrq.gov/cahps
Goals for narrative elicitation: specifics
We aspired to collect narratives that are:
• Complete: provide a full picture of the experiences that
matter…
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www.qualitymeasures.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apd.html
August 01, 2022 - FUTURE RISKS
Are there other areas in the organization where this could happen?
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www.qualitymeasures.ahrq.gov/questions/videos/patient-mcgregor.html
November 01, 2020 - I happen to be the car."
-
www.qualitymeasures.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-slides.html
July 01, 2023 - Question 2: Why did it happen?
Question 3: What will you do to reduce the risk of reoccurrence? … Defects or failures are clinical or operational events that you do not want to happen again.