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effectivehealthcare-admin.ahrq.gov/health-topics/jaundice
However, jaundice can happen at any age and may be a sign of a problem. … Jaundice can happen for many reasons, such as
Blood diseases
Genetic syndromes
Liver diseases
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effectivehealthcare-admin.ahrq.gov/health-topics/elder-abuse
April 15, 2013 - It can happen within the family. … It can also happen in assisted living facilities or nursing homes.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/visual/visual-mgmt-pdsa-form.docx
May 01, 2017 - reviewed during huddle; if huddle is not scheduled regularly yet, let all relevant staff know huddle will happen … Predict what will happen when the test is carried out (e.g., if we do “x,” “y” will happen)
Measures … When to be done
Where to be done
Predict what will happen … when the test is carried out (i.e., if we do “x,” “y” will happen)
Measures to compare prediction
-
www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/visual/visual-mgmt-pdsa-form.docx
May 01, 2017 - reviewed during huddle; if huddle is not scheduled regularly yet, let all relevant staff know huddle will happen … Predict what will happen when the test is carried out (e.g., if we do “x,” “y” will happen)
Measures … When to be done
Where to be done
Predict what will happen … when the test is carried out (i.e., if we do “x,” “y” will happen)
Measures to compare prediction
-
www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/visual/visual-mgmt-pdsa-form.docx
May 01, 2017 - reviewed during huddle; if huddle is not scheduled regularly yet, let all relevant staff know huddle will happen … Predict what will happen when the test is carried out (e.g., if we do “x,” “y” will happen)
Measures … When to be done
Where to be done
Predict what will happen … when the test is carried out (i.e., if we do “x,” “y” will happen)
Measures to compare prediction
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www.innovations.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/visual/visual-mgmt-pdsa-form.docx
May 01, 2017 - reviewed during huddle; if huddle is not scheduled regularly yet, let all relevant staff know huddle will happen … Predict what will happen when the test is carried out (e.g., if we do “x,” “y” will happen)
Measures … When to be done
Where to be done
Predict what will happen … when the test is carried out (i.e., if we do “x,” “y” will happen)
Measures to compare prediction
-
www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/visual/visual-mgmt-pdsa-form.docx
May 01, 2017 - reviewed during huddle; if huddle is not scheduled regularly yet, let all relevant staff know huddle will happen … Predict what will happen when the test is carried out (e.g., if we do “x,” “y” will happen)
Measures … When to be done
Where to be done
Predict what will happen … when the test is carried out (i.e., if we do “x,” “y” will happen)
Measures to compare prediction
-
www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/visual/visual-mgmt-pdsa-form.docx
May 01, 2017 - reviewed during huddle; if huddle is not scheduled regularly yet, let all relevant staff know huddle will happen … Predict what will happen when the test is carried out (e.g., if we do “x,” “y” will happen)
Measures … When to be done
Where to be done
Predict what will happen … when the test is carried out (i.e., if we do “x,” “y” will happen)
Measures to compare prediction
-
www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/visual/visual-mgmt-pdsa-form.docx
May 01, 2017 - reviewed during huddle; if huddle is not scheduled regularly yet, let all relevant staff know huddle will happen … Predict what will happen when the test is carried out (e.g., if we do “x,” “y” will happen)
Measures … When to be done
Where to be done
Predict what will happen … when the test is carried out (i.e., if we do “x,” “y” will happen)
Measures to compare prediction
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www.ahrq.gov/sites/default/files/wysiwyg/patients-consumers/care-planning/errors/20tips/20tips.pdf
September 01, 2011 - They can happen during
even the most routine tasks, such as when a hospital
patient on a saltfree … But errors also happen
when doctors* and patients have problems
communicating. … If you know
what might happen, you will be better prepared
if it does or if something unexpected happens
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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…
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/medical-office-survey-english-2023.docx
January 01, 2023 - SECTION A: List of Patient Safety and Quality Issues
The following items describe things that can happen … In your best estimate, how often did the following things happen in your medical office OVER THE PAST … They overlook patient care mistakes that
happen over and over
1
2
3
4
5
9
3. … Mistakes happen more than they should
in this office
1
2
3
4
5
9
4. … This office is good at changing office processes to make sure the same problems don’t happen again
-
preventiveservices.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/medical-office-survey-english-2023.docx
January 01, 2023 - SECTION A: List of Patient Safety and Quality Issues
The following items describe things that can happen … In your best estimate, how often did the following things happen in your medical office OVER THE PAST … They overlook patient care mistakes that
happen over and over
1
2
3
4
5
9
3. … Mistakes happen more than they should
in this office
1
2
3
4
5
9
4. … This office is good at changing office processes to make sure the same problems don’t happen again
-
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
-
www.ahrq.gov/questions/videos/patient-mcgregor.html
November 01, 2020 - I happen to be the car."
-Alastair McGregor
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/userguide/hospital-survey-items.pdf
July 25, 2017 - 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. (negatively worded)
A17. … We are informed about errors that happen in this unit.
C5.
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effectivehealthcare-admin.ahrq.gov/health-topics/seizures
December 21, 2011 - They happen because of sudden, abnormal
electrical activity in the brain. … Focal
seizures, also called partial seizures, happen in just one part of the brain.
-
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
-
www.ahrq.gov/sops/international/hospital/translators-version-2.html
October 01, 2024 - (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.
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www.ahrq.gov/hai/cusp/modules/identify/identify.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 the risk of recurrence? … (vignette still)
Click to play
Return to Contents
Slide 23: Why Did It Happen? … Defects or failures are clinical or operational events that you do not want to happen again.