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Total Results: 3,974 records

Showing results for "happen".

141. Sorry Works! | PSNet
     psnet.ahrq.gov/issue/sorry-works
     November 15, 2024 - They encourage doctors and their insurers to be honest when mistakes happen, offer apologies, and provide

142. 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?

143. 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

144. Nursing Home Survey on Patient Safety Culture: Background and Information for Translators (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/nursing-home/resources/infotransNHSOPS.pdf
     January 01, 2010 - expect supervisors to investigate all factors, including systems reasons, to determine why mistakes happen … Sometimes, Most of the time, Always, Does Not Apply or Don’t Know) How often do the following things happen … Sometimes, Most of the time, Always, Does Not Apply or Don’t Know) How often do the following things happen … Sometimes, Most of the time, Always, Does Not Apply or Don’t Know) How often do the following things happen … This nursing home lets the same mistakes happen again and again. (negatively worded) D4.

145. Fatal mistakes: why do ten-fold medication errors in children keep happening? | PSNet
     psnet.ahrq.gov/issue/fatal-mistakes-why-do-ten-fold-medication-errors-children-keep-happening
     April 21, 2021 - View More Related Resources Prescribing errors in children: why they happen

146. Scoring Different Kinds of Health Care Quality Measures | Agency for Healthcare Research and Quality
     www.ahrq.gov/talkingquality/translate/scores/scoring.html
     June 01, 2016 - Do you want to tell people how often this event happened or how often it did not happen? … Experience indicates that in this case, saying how often a patient safety event did happen will be

147. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/851870/psn-pdf
     July 31, 2023 - that is a known risk of wheelchair usage, it is not one that staff may often think about or expect to happen … When we reviewed the event, we noted there is a warning on the package insert that a reaction could happen … It does not happen often, and most people don’t make that association. … What actions are you taking as an organization to make sure that this does not happen again? … still be viewed as airing dirty laundry, instead of sharing adverse events so similar events do not happen

148. Engage the Team and Applying CUSP in the ICU Setting Slides (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cusp-icu-notes.docx
     April 01, 2022 - As we discussed at the beginning of this presentation, staff need a clear understanding of what will happen … · Why did it happen? · How will you reduce the risk of the defect happening again? … Slide 14 In order for the CUSP team to better understand why defects happen, make the "whys" visual

149. A national mixed-methods evaluation of preparedness for general surgery residency and the association with resident burnout. | PSNet
     psnet.ahrq.gov/issue/national-mixed-methods-evaluation-preparedness-general-surgery-residency-and-association
     September 02, 2020 - September 9, 2020 When bad things happen: training medical students to anticipate the … September 2, 2020 Surgical errors happen, but are learners trained to recover from them

150. Transcript: How To Address Attitudes and Beliefs Around Infection Prevention Strategies and Techniques (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/attitudes-beliefs-transcript.pdf
     April 01, 2022 - So, it can happen. And it does happen. And there's plenty in the literature. … that help us to get there, that improve teamwork, improve communication, that all show that this can happen … So, we know it can happen. … So, to share successes like that, yes, it does happen.

151. Identify Defects Through Sensemaking, Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/modules/identify/notes.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 risk? … Why did it happen? Step 1. Visualize the factors that led to the event. Step 2. … Return to Contents   Slide 23: Why Did It Happen? Do: Play the video. … Defects are clinical or operational events that you do not want to happen again.

152. One doctor. 25 deaths. How could it have happened? | PSNet
     psnet.ahrq.gov/issue/one-doctor-25-deaths-how-could-it-have-happened
     November 06, 2019 - Newspaper/Magazine Article One doctor. 25 deaths. How could it have happened? Citation Text: One doctor. 25 deaths. How could it have happened? Healy J, Farr I, Feiger L, Duffy C. New York Times. October 11, 2019. Copy Citation Save Save to your library P…

153. 148-Investigating-Defect-Lfd-Worksheet (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/148-investigating-defect-lfd-worksheet.docx
     June 02, 2025 - ___________________ Revision Date: _________________________ How Can We Reduce the Chance This Will Happen

154. In Conversation With… Christine Cassel, MD | PSNet
     psnet.ahrq.gov/perspective/conversation-christine-cassel-md
     February 26, 2025 - list, and the definition is serious and harmful, largely preventable, patient safety issues—harms that happen … ; medication errors should never happen. … So we are eager to work with the electronic data world in order to make that happen. … But it's very hard to measure something that doesn't happen. … The patient safety world is all about measuring when mistakes or bad things happen.

155. Sensemakingnotes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/identify/sensemakingnotes.docx
     June 02, 2025 - · Why did it happen? · What will you do to reduce risk? … categorized in three main types: skill-based, rule-based, and knowledge-based. · Skill-based failures happen … 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 We then ask why … Why did it happen? · Step 1. Visualize the factors that led to the event. · Step 2.

156. Safety culture and the positive association of being a primary care training practice during COVID-19: the results of the multi-country European PRICOV-19 Study. | PSNet
     psnet.ahrq.gov/issue/safety-culture-and-positive-association-being-primary-care-training-practice-during-covid-19
     January 08, 2025 - Improving Diagnostic Safety and Quality April 26, 2023 Bad things can happen … September 30, 2020 When bad things happen: training medical students to anticipate the

157. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49473/psn-pdf
     March 01, 2005 - result of a complex system with multiple communication failures, which is how most medical mistakes happen … No one had the big picture of what was supposed to happen. … result of a complex system with multiple communication failures, which is how most medical mistakes happen … No one had the big picture of what was supposed to happen. … concern, and the promotion of situational awareness, where all the team members know what is going to happen

158. Improving Patient Safety in Long-Term Care Facilities, Module 2 (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/ltcmodule2.pdf
     June 01, 2012 - 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 … Following up – The next step is being clear about what will happen after the message is given and received … Recommendation: › What should happen next? › What do you need? › Timeframe? … above the therapeutic range.” › Then, in an SBAR recommendation, say what you think might need to happen

159. Changing-System-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-facilitator-guide.docx
     June 01, 2021 - They are considered latent because they have to do with how the work environment was set up and could happen … · Why did it happen? · What could you do to reduce the risk of this happening again? … Slide 13 Why Did It Happen?

160. Ambulatory Surgery Center Survey on Patient Safety Culture: Composites and Items (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/composite-measures-english.pdf
     January 01, 2015 - We are good at changing processes to make sure the same patient safety problems don’t happen again. … Staff are told about patient safety problems that happen in this facility.