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Total Results: 3,974 records

Showing results for "happen".

121. 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.

122. Appendix B17: Handout for Inservice #1, Why Falls Happen in Nursing Facilities | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb17.html
     December 01, 2017 - Quality Improvement Initiative for Nursing Facilities Appendix B17: Handout for Inservice #1, Why Falls Happen

123. Appendix B15: Pre and Posttests for Inservice #1, Why Falls Happen, Spanish | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb15.html
     December 01, 2017 - Improvement Initiative for Nursing Facilities Appendix B15: Pre and Posttests for Inservice #1, Why Falls Happen

124. 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

125. Carman-notes-151021 copy-Teresa (pdf file)
     effectivehealthcare.ahrq.gov/sites/default/files/carman-presentation.pdf
     October 08, 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.  

126. 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.

127. 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?”

128. 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

129. 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

130. 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."

131. 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…

132. 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

133. 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

134. 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?

135. Geriatric Depression Scale-15 (short version) (pdf file)
     integrationacademy.ahrq.gov/sites/default/files/2020-07/Update_Geriatric_Depression_Scale-15.pdf
     January 01, 2020 - Are you afraid that something bad is going to happen to you? YES / NO 7. … Are you afraid that something bad is going to happen to you? YES / NO 7.

136. 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.

137. Teaching medical error apologies: development of a multi-component intervention. | PSNet
     psnet.ahrq.gov/issue/teaching-medical-error-apologies-development-multi-component-intervention
     August 04, 2021 - October 19, 2022 Surgical safety does not happen by accident: learning from perioperative … July 26, 2023 View More Related Resources Bad things can happen

138. 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.

139. 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 …

140. 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.