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digital.ahrq.gov/sites/default/files/docs/workflowtoolkit/HowDoIEvaluateWorkflow.ppt
December 18, 2021 - Goals of a flowchart
To show how processes really happen, as opposed to how they are supposed to happen … or how we expect they happen.
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursing-home-survey-english.pdf
September 01, 2024 - 1 2 3 4 5 9
SECTION B: Communications
How often do the following things happen
in your nursing … 1 2 3 4 5 9
3
SECTION B: Communications (continued)
How often do the following things happen … This nursing home lets the same mistakes
happen again and again .............................
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psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph-0
March 24, 2025 - There has been some survey research, and an unsurprising finding is that after these things happen, people … We really feel bad when bad things happen. We all want to behave like human beings. … I think it's because we have such a disbelief that these things happen that when something really goes
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digital.ahrq.gov/sites/default/files/docs/resource/PCC_Lapane_Q2_Focus_Groups_Consent_Form.pdf
June 16, 2021 - If you decide to participate in the study, here is what will happen:
You will take part in one 2-hour … These risks or discomforts have been known to happen; they could happen to you:
Risks or Discomforts
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/SOPS-Hospital-Survey-2.0-5-26-2021.pdf
January 01, 2021 - 1 2 3 4 5 9
SECTION C: Communication
How often do the following things happen in your unit … We are informed about errors that happen in
this unit ............................................ … When errors happen in this unit, we discuss
ways to prevent them from happening again .. 1 2 3 4
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-facilitator-guide.docx
May 01, 2017 - 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?
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psnet.ahrq.gov/node/73542/psn-pdf
July 28, 2021 - psnet.ahrq.gov/issue/diagnostic-safety-event-reporting
Adverse event reporting can clarify when mistakes happen
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www.ahrq.gov/hai/cusp/videos/index.html
September 01, 2019 - Why Did It Happen?
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/understand/scisafetynotes.docx
June 02, 2025 - The first step in comprehending why they happen is accepting the fact 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? … and patient procedures), and create a communication plan to address any identified issues that may happen
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Encinosa.pdf
January 01, 2003 - What Happens After a Patient Safety Event? Medical Expenditures and Outcomes in Medicare
423
What Happens After a Patient Safety Event?
Medical Expenditures and Outcomes
in Medicare
William E. Encinosa, Fred J. Hellinger
Abstract
Objective: To estimate the impact of potentially preventable adverse event…
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psnet.ahrq.gov/node/33878/psn-pdf
April 01, 2019 - Politically, how were they able to make that happen?
JM: The history is interesting. … Often an investigation needs to happen to elucidate the facts if it's
a complex error.
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/2024-medical-office-database-report-rev.pdf
January 01, 2024 - (Item F2) 84%
Mistakes happen more than they should in this office. … (Item E1*)
46%
They overlook patient care mistakes that happen over and over. … In your best estimate, how often did the following things happen in your
medical office OVER THE PAST … In your best estimate, how often did the following things happen in your
medical office OVER THE PAST … (Item E1*)
46% 23.11% 0% 17% 30% 45% 63% 75% 100%
They overlook patient care mistakes that happen
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psnet.ahrq.gov/perspective/conversation-jennifer-schulz-moore-llb-ma-phd
February 26, 2025 - Politically, how were they able to make that happen?
JM : The history is interesting. … Often an investigation needs to happen to elucidate the facts if it's a complex error.
-
psnet.ahrq.gov/node/33788/psn-pdf
June 01, 2015 - , 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.
-
www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/patient-narratives-webinar-ahrq.pdf
June 02, 2025 - care
Standardized surveys: What happened to the patient in the care
encounter, or how often did it happen
-
psnet.ahrq.gov/node/33678/psn-pdf
January 01, 2009 - We also know very little about how patients want disclosure to happen in the
moment. … organization are
doing to mitigate the harm to that particular patient and fix the problem so it doesn't happen
-
psnet.ahrq.gov/node/854642/psn-pdf
October 18, 2023 - This eight-episode video series provides an overview
for non-technologists on how cyberattacks happen
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-surgery/111-cusp-learning-from-defects-worksheet.docx
April 01, 2025 - How Can We Reduce the Chance This Will Happen Again?
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/111-ss-cusp-lfd-worksheet-a3.docx
April 01, 2025 - How Can We Reduce the Chance This Will Happen Again?
-
www.ahrq.gov/hai/cusp/toolkit/content-calls/briefing-slides/slides.html
October 01, 2014 - An Overview
Members of the team have an understanding of what’s going on and what is likely to happen … competence
Who has what skills
Who performs what
Who knows what
Predicts what will happen