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Total Results: 3,974 records

Showing results for "happen".

101. 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

102. 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

103. What We Planned, What Happened, and What We Learned | Agency for Healthcare Research and Quality
     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…

104. 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.

105. 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.

106. 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

107. 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

108. 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

109. 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

110. 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

111. 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?

112. 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

113. 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?

114. 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?

115. 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?

116. 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?

117. 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?

118. 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.

119. 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

120. 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.