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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
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www.ahrq.gov/takeheart/assessing/slide-presentation/index.html
August 01, 2023 - What We Planned, What Happened, and What We Learned
TAKEheart: AHRQ's Initiative to Increase Patient Participation in Cardiac Rehabilitation
This PowerPoint Presentation explores what the AHRQ TAKEheart team planned from this project, what happened, and what was learned.
It was presented by Michael Harrison…
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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.
-
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
-
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
-
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
-
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?
-
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?
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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
-
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.
-
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.
-
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
-
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?
-
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.
-
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
-
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
-
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?
-
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?
-
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
-
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