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Showing results for "happen".

181. Sensemaking and Learn From Defects for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-fac-guide.html
     July 01, 2023 - Why did it happen? What will you do to reduce risk? … 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. … 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.

182. 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

183. Hospital SOPS Translation Information | Agency for Healthcare Research and Quality
     www.ahrq.gov/sops/international/hospital/translators.html
     October 01, 2014 - 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. … In other words, the reason mistakes do not happen more often is good luck, not because procedures or … We are informed about errors that happen in this unit. C5. … worded) ( More about this item: Shift changes cause problems for patients in this hospital—problems happen

184. 130-Ss-Swiss-Cheese-Fg (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/130-ss-swiss-cheese-fg.docx
     April 01, 2025 - SAY: A defect is broadly defined as “Anything you do not want to happen again.” … failures are the “holes in the system”—the weaknesses that create conditions for an active failure to happen … These outcomes are “defects”—the events that the team does not want to happen again. … When errors happen, attention is often focused on individual provider behavior or actions. … When defects happen, it is essential to use new lenses to identify systems in play and be vigilant in

185. 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?”

186. Hospital Survey on Patient Safety Culture: Background and Information for Translators (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/resources/infotranshsops.pdf
     September 01, 2009 - 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. … worded) (More about this item: It is because of good luck or good fortune that more mistakes do not happen … In other words, the reason mistakes do not happen more often is good luck, NOT because procedures or … We are informed about errors that happen in this unit. C5.

187. Plan-Do-Study-Act Worksheet (pdf file)
     www.cahps.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/pdsa-worksheet.pdf
     August 20, 2018 - ______________________________________________________________________ What do you predict will happen … What do you need to do to get ready: How will you evaluate how it went: What do you predict will happen

188. Plan-Do-Study-Act Worksheet (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/pdsa-worksheet.pdf
     August 20, 2018 - ______________________________________________________________________ What do you predict will happen … What do you need to do to get ready: How will you evaluate how it went: What do you predict will happen

189. 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 …

190. Appendix B. Forms and Training Materials (Appendix Contents) | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb.html
     December 01, 2017 - Plan Fall Interventions Monitor Staff Materials Pre and Posttests for Inservice #1, Why Falls Happen … and Posttests for Inservice #2, How to Reduce Falls Pre and Posttests for Inservice #1, Why Falls Happen … for Inservice #2, How to Reduce Falls, Spanish Appendix B17: Handout for Inservice #1, Why Falls Happen … Inservice #2, How to Reduce Falls in Nursing Facilities Appendix B19: Handout for Inservice #1, Why Falls Happen

191. Shock | Effective Health Care (EHC) Program
     effectivehealthcare-admin.ahrq.gov/health-topics/shock
     December 15, 2009 - This may happen after a heart attack. Neurogenic shock is caused by damage to the nervous system.

192. 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

193. Learning From Defects Through Sensemaking: Slide Presentation | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-slides.html
     December 01, 2017 - Anything you do not want to happen again. … (From view of person involved) Why did it happen? … Slide 15: Why Did It Happen? … Slide 16: Why Did It Happen? … Slide 22: Why Did It Happen?

194. Diagnostic Safety and Quality | Agency for Healthcare Research and Quality
     pcmh.ahrq.gov/diagnostic-safety/index.html
     January 01, 2007 - Diagnostic Safety and Quality Learn about AHRQ's research to better understand how diagnostic errors happen … AHRQ funds research to better understand how diagnostic errors happen and what can be done to prevent

195. Diagnostic Safety and Quality | Agency for Healthcare Research and Quality
     pbrn.ahrq.gov/diagnostic-safety/index.html
     January 01, 2007 - Diagnostic Safety and Quality Learn about AHRQ's research to better understand how diagnostic errors happen … AHRQ funds research to better understand how diagnostic errors happen and what can be done to prevent

196. Appendix B15: Pre and Posttests for Inservice #1, Why Falls Happen, Spanish | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb15.html
     December 01, 2017 - Resources Injuries Appendix B15: Pre and Posttests for Inservice #1, Why Falls Happen … Improvement Initiative for Nursing Facilities Appendix B15: Pre and Posttests for Inservice #1, Why Falls Happen … February 2010 Internet Citation: Appendix B15: Pre and Posttests for Inservice #1, Why Falls Happen

197. 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

198. AHRQ_Brand_NameOnly (xls file)
     www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/sustainability/sustainability-assesment-tool.xlsx
     March 01, 2017 - Who will make this happen? How do I know to move to next step? … [Be specific and include important steps to make the idea/activity happen.] … I need to make this happen? … Who will make this happen? [Be specific for each task.] When will this happen? … What other information do I need to make this happen?

199. AHRQ_Brand_NameOnly (xls file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/sustainability/sustainability-assesment-tool.xlsx
     March 01, 2017 - Who will make this happen? How do I know to move to next step? … [Be specific and include important steps to make the idea/activity happen.] … I need to make this happen? … Who will make this happen? [Be specific for each task.] When will this happen? … What other information do I need to make this happen?

200. AHRQ_Brand_NameOnly (xls file)
     preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/sustainability/sustainability-assesment-tool.xlsx
     March 01, 2017 - Who will make this happen? How do I know to move to next step? … [Be specific and include important steps to make the idea/activity happen.] … I need to make this happen? … Who will make this happen? [Be specific for each task.] When will this happen? … What other information do I need to make this happen?