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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/088-or-traffic.pptx
April 01, 2025 - Why did it happen?
How to reduce the likelihood of this defect happening again? … discussion focused around OR traffic
Members felt that door openings during the surgical case appeared to happen … AHRQ Safety Program for MRSA Prevention | Surgical Services
OR Traffic
14
Case Example: Why Did It Happen
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.doc
November 15, 2019 - It is just by chance that more serious mistakes don’t happen around here
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11. … My supervisor/manager overlooks patient safety problems that happen over and over
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SECTION C: Communications
How often do the following things happen in your work area/unit? … We are informed about errors that happen in this unit
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4. … (5
SECTION D: Frequency of Events Reported
In your work area/unit, when the following mistakes happen
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.doc
November 15, 2019 - It is just by chance that more serious mistakes don’t happen around here
(1
(2
(3
(4
(5
11. … My supervisor/manager overlooks patient safety problems that happen over and over
(1
(2
(3
(4
( … 5
SECTION C: Communications
How often do the following things happen in your work area/unit? … We are informed about errors that happen in this unit
(1
(2
(3
(4
(5
4. … (5
SECTION D: Frequency of Events Reported
In your work area/unit, when the following mistakes happen
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www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.doc
November 15, 2019 - It is just by chance that more serious mistakes don’t happen around here
(1
(2
(3
(4
(5
11. … My supervisor/manager overlooks patient safety problems that happen over and over
(1
(2
(3
(4
( … 5
SECTION C: Communications
How often do the following things happen in your work area/unit? … We are informed about errors that happen in this unit
(1
(2
(3
(4
(5
4. … (5
SECTION D: Frequency of Events Reported
In your work area/unit, when the following mistakes happen
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.doc
November 15, 2019 - It is just by chance that more serious mistakes don’t happen around here
(1
(2
(3
(4
(5
11. … My supervisor/manager overlooks patient safety problems that happen over and over
(1
(2
(3
(4
( … 5
SECTION C: Communications
How often do the following things happen in your work area/unit? … We are informed about errors that happen in this unit
(1
(2
(3
(4
(5
4. … (5
SECTION D: Frequency of Events Reported
In your work area/unit, when the following mistakes happen
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www.monahrq.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.doc
November 15, 2019 - It is just by chance that more serious mistakes don’t happen around here
(1
(2
(3
(4
(5
11. … My supervisor/manager overlooks patient safety problems that happen over and over
(1
(2
(3
(4
( … 5
SECTION C: Communications
How often do the following things happen in your work area/unit? … We are informed about errors that happen in this unit
(1
(2
(3
(4
(5
4. … (5
SECTION D: Frequency of Events Reported
In your work area/unit, when the following mistakes happen
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.doc
November 15, 2019 - It is just by chance that more serious mistakes don’t happen around here
(1
(2
(3
(4
(5
11. … My supervisor/manager overlooks patient safety problems that happen over and over
(1
(2
(3
(4
( … 5
SECTION C: Communications
How often do the following things happen in your work area/unit? … We are informed about errors that happen in this unit
(1
(2
(3
(4
(5
4. … (5
SECTION D: Frequency of Events Reported
In your work area/unit, when the following mistakes happen
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www.innovations.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.doc
November 15, 2019 - It is just by chance that more serious mistakes don’t happen around here
(1
(2
(3
(4
(5
11. … My supervisor/manager overlooks patient safety problems that happen over and over
(1
(2
(3
(4
( … 5
SECTION C: Communications
How often do the following things happen in your work area/unit? … We are informed about errors that happen in this unit
(1
(2
(3
(4
(5
4. … (5
SECTION D: Frequency of Events Reported
In your work area/unit, when the following mistakes happen
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pcmh.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.doc
November 15, 2019 - It is just by chance that more serious mistakes don’t happen around here
(1
(2
(3
(4
(5
11. … My supervisor/manager overlooks patient safety problems that happen over and over
(1
(2
(3
(4
( … 5
SECTION C: Communications
How often do the following things happen in your work area/unit? … We are informed about errors that happen in this unit
(1
(2
(3
(4
(5
4. … (5
SECTION D: Frequency of Events Reported
In your work area/unit, when the following mistakes happen
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pbrn.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.doc
November 15, 2019 - It is just by chance that more serious mistakes don’t happen around here
(1
(2
(3
(4
(5
11. … My supervisor/manager overlooks patient safety problems that happen over and over
(1
(2
(3
(4
( … 5
SECTION C: Communications
How often do the following things happen in your work area/unit? … We are informed about errors that happen in this unit
(1
(2
(3
(4
(5
4. … (5
SECTION D: Frequency of Events Reported
In your work area/unit, when the following mistakes happen
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patientregistry.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.doc
November 15, 2019 - It is just by chance that more serious mistakes don’t happen around here
(1
(2
(3
(4
(5
11. … My supervisor/manager overlooks patient safety problems that happen over and over
(1
(2
(3
(4
( … 5
SECTION C: Communications
How often do the following things happen in your work area/unit? … We are informed about errors that happen in this unit
(1
(2
(3
(4
(5
4. … (5
SECTION D: Frequency of Events Reported
In your work area/unit, when the following mistakes happen
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ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.doc
November 15, 2019 - It is just by chance that more serious mistakes don’t happen around here
(1
(2
(3
(4
(5
11. … My supervisor/manager overlooks patient safety problems that happen over and over
(1
(2
(3
(4
( … 5
SECTION C: Communications
How often do the following things happen in your work area/unit? … We are informed about errors that happen in this unit
(1
(2
(3
(4
(5
4. … (5
SECTION D: Frequency of Events Reported
In your work area/unit, when the following mistakes happen
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teamstepps.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.doc
November 15, 2019 - It is just by chance that more serious mistakes don’t happen around here
(1
(2
(3
(4
(5
11. … My supervisor/manager overlooks patient safety problems that happen over and over
(1
(2
(3
(4
( … 5
SECTION C: Communications
How often do the following things happen in your work area/unit? … We are informed about errors that happen in this unit
(1
(2
(3
(4
(5
4. … (5
SECTION D: Frequency of Events Reported
In your work area/unit, when the following mistakes happen
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.doc
November 15, 2019 - It is just by chance that more serious mistakes don’t happen around here
(1
(2
(3
(4
(5
11. … My supervisor/manager overlooks patient safety problems that happen over and over
(1
(2
(3
(4
( … 5
SECTION C: Communications
How often do the following things happen in your work area/unit? … We are informed about errors that happen in this unit
(1
(2
(3
(4
(5
4. … (5
SECTION D: Frequency of Events Reported
In your work area/unit, when the following mistakes happen
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monahrq.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.doc
November 15, 2019 - It is just by chance that more serious mistakes don’t happen around here
(1
(2
(3
(4
(5
11. … My supervisor/manager overlooks patient safety problems that happen over and over
(1
(2
(3
(4
( … 5
SECTION C: Communications
How often do the following things happen in your work area/unit? … We are informed about errors that happen in this unit
(1
(2
(3
(4
(5
4. … (5
SECTION D: Frequency of Events Reported
In your work area/unit, when the following mistakes happen
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cahps.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.doc
November 15, 2019 - It is just by chance that more serious mistakes don’t happen around here
(1
(2
(3
(4
(5
11. … My supervisor/manager overlooks patient safety problems that happen over and over
(1
(2
(3
(4
( … 5
SECTION C: Communications
How often do the following things happen in your work area/unit? … We are informed about errors that happen in this unit
(1
(2
(3
(4
(5
4. … (5
SECTION D: Frequency of Events Reported
In your work area/unit, when the following mistakes happen
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.doc
November 15, 2019 - It is just by chance that more serious mistakes don’t happen around here
(1
(2
(3
(4
(5
11. … My supervisor/manager overlooks patient safety problems that happen over and over
(1
(2
(3
(4
( … 5
SECTION C: Communications
How often do the following things happen in your work area/unit? … We are informed about errors that happen in this unit
(1
(2
(3
(4
(5
4. … (5
SECTION D: Frequency of Events Reported
In your work area/unit, when the following mistakes happen
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.doc
November 15, 2019 - It is just by chance that more serious mistakes don’t happen around here
(1
(2
(3
(4
(5
11. … My supervisor/manager overlooks patient safety problems that happen over and over
(1
(2
(3
(4
( … 5
SECTION C: Communications
How often do the following things happen in your work area/unit? … We are informed about errors that happen in this unit
(1
(2
(3
(4
(5
4. … (5
SECTION D: Frequency of Events Reported
In your work area/unit, when the following mistakes happen
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effectivehealthcare-admin.ahrq.gov/health-topics/urinary-incontinence
September 14, 2018 - It can happen to anyone, but it becomes more common with age. … Most bladder control problems happen when muscles are too weak or too active.
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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?