Results

Total Results: 4,075 records

Showing results for "happen".

141. 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.

142. 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.

143. 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

144. 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.

145. 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

146. 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

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. 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.

150. 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.

151. 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

152. 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

153. 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.

154. 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.

155. 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

156. 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

157. 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

158. 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?

159. 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.

160. 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