U.S. flag

An official website of the Department of Health & Human Services

AHRQ: Agency for Healthcare Research and Quality

Search AHRQ

For an exact phrase match, enclose search terms in double quotes.

Go to Advanced Search
Go to Basic Search

Results

Total Results: 4,075 records

Showing results for "happen".

  1. 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?

  2. 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.

  3. 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

  4. 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.

  5. 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

  6. 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?”

  7. Using Aviation Technology to Prevent Healthcare Errors: The Health IT Black Box | Digital Healthcare Research

    digital.ahrq.gov/2019-year-review/research-summary/using-aviation-technology-prevent-healthcare-errors-health-it
    January 01, 2019 - Profile: Context is Critical: Understanding When and Why Electronic Health Record-Related Safety Hazards Happen … improvements in EHR design and usability As a practicing clinician, you see themes of errors that happen … They happen over and over again and more than 99 percent of the time nothing bad happens.

  8. 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.

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848382/psn-pdf
    May 03, 2023 - Events that inspired change: the importance of sharing what happened to stop it from happening again. May 3, 2023 Myers E, Allen C. Events that inspired change: the importance of sharing what happened to stop it from happening again. Patient Saf. 2023;5(1):62-63. doi:10.33940/001c.74079. https://psnet.ahrq.gov/iss…

  10. Carman-notes-151021 copy-Teresa (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/carman-presentation.pdf
    May 29, 2025 - “ How do we make engagement happen?” … “What are the different ways in  which   we can  make it happen?” … Well, it can’t happen  in  ten  minutes.   … It needs to happen every week at church. It needs to happen at the bridge club. … It needs to happen  at a variety of places.  

  11. 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

  12. 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

  13. 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

  14. 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."

  15. 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.

  16. 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

  17. 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 …

  18. 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?

  19. 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?

  20. 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
SHARE:
Facebook Twitter Print Facebook Share

Similar Terms:

Search the AHRQ Archive

Information and reports more than 5 years old may be found in the AHRQ Archive site.

Search Archive

Search Within A Specific AHRQ Site

Click to show only results for the selected site.

psnet.ahrq.gov (1692)

www.ahrq.gov (1577)

effectivehealthcare.ahrq.gov (363)

digital.ahrq.gov (266)

www.uspreventiveservicestaskforce.org (63)

hcup-us.ahrq.gov (57)

integrationacademy.ahrq.gov (16)

meps.ahrq.gov (16)

cds.ahrq.gov (8)

cdsic.ahrq.gov (5)

pso.ahrq.gov (5)

qualityindicators.ahrq.gov (5)

datatools.ahrq.gov (2)