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Showing results for "happen".

221. Survey on Patient Safety (facility version) (pdf file)
     www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.pdf
     November 18, 2019 - It is just by chance that more serious mistakes don’t happen around here .......................... … My supervisor/manager overlooks patient safety problems that happen over and over .................. … 1 2 3 4 5 3 SECTION C: Communications How often do the following things happen … We are informed about errors that happen in this unit .............................. 1 2 3 4 5 … SECTION D: Frequency of Events Reported In your work area/unit, when the following mistakes happen

222. Survey on Patient Safety (facility version) (pdf file)
     www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.pdf
     November 18, 2019 - It is just by chance that more serious mistakes don’t happen around here .......................... … My supervisor/manager overlooks patient safety problems that happen over and over .................. … 1 2 3 4 5 3 SECTION C: Communications How often do the following things happen … We are informed about errors that happen in this unit .............................. 1 2 3 4 5 … SECTION D: Frequency of Events Reported In your work area/unit, when the following mistakes happen

223. Survey on Patient Safety (facility version) (pdf file)
     www.cpsi.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.pdf
     November 18, 2019 - It is just by chance that more serious mistakes don’t happen around here .......................... … My supervisor/manager overlooks patient safety problems that happen over and over .................. … 1 2 3 4 5 3 SECTION C: Communications How often do the following things happen … We are informed about errors that happen in this unit .............................. 1 2 3 4 5 … SECTION D: Frequency of Events Reported In your work area/unit, when the following mistakes happen

224. Survey on Patient Safety (facility version) (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.pdf
     November 18, 2019 - It is just by chance that more serious mistakes don’t happen around here .......................... … My supervisor/manager overlooks patient safety problems that happen over and over .................. … 1 2 3 4 5 3 SECTION C: Communications How often do the following things happen … We are informed about errors that happen in this unit .............................. 1 2 3 4 5 … SECTION D: Frequency of Events Reported In your work area/unit, when the following mistakes happen

225. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/module5-response-disclosure-notes.pptx
     August 21, 2015 - Why did it happen? How will the organization prevent the event from happening to another patient? … Why did the event happen? … issue and redirect the conversation toward a shared goal of ensuring that a similar event does not happen

226. Appendix B19: Handout 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/fallspxmanapb19.html
     December 01, 2017 - Care Resources Injuries Appendix B19: Handout for Inservice #1, Why Falls Happen … Quality Improvement Initiative for Nursing Facilities Appendix B19: Handout for Inservice #1, Why Falls Happen … created February 2010 Internet Citation: Appendix B19: Handout for Inservice #1, Why Falls Happen

227. 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

228. Understand the Science of Safety for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/understand-sci-fac-guide.html
     July 01, 2023 - Slide 4: How Can These Errors Happen? … 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?

229. 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

230. Sensemaking and Learn From Defects for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/perinatal-care/modules/teamwork/learn-from-defects-fac-guide.html
     May 01, 2017 - 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.

231. Learn-From-Defects-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.docx
     May 01, 2017 - Why did it happen? What will you do to reduce risk? … Skill-based failures happen when a person fails in the performance of a routine task that normally requires … The consequent event is described in terms of the event’s consequences: Harm that did happen Harm that … 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.

232. Approach to Residents With Reported Penicillin Allergy (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/penicillin-allergy.pdf
     June 01, 2021 - _______________ o How soon after starting the antibiotic did the reaction happen (e.g., minutes to hours … by: Datetime: Reviewed by physician: How soon after starting the antibiotic did the reaction happen

233. 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

234. Presentation: Program Overview
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/learn-from-defects-slides.pptx
     January 01, 2017 - A defect is any clinical or operational event or situation that you would not want to happen again. … From the view of the person involved Why did it happen? … Learn From Defects ‹#› AHRQ Safety Program for Mechanically Ventilated Patients 14 Why Did It Happen … Why Did It Happen? … Why Did It Happen?

235. Transcript: How To Have Difficult Conversations With Colleagues Around Infection Prevention Practices (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/difficult-conversations-transcript.pdf
     April 01, 2022 - preventing patient errors, the first step is really about setting expectations that communications will happen … Like in the nursing world, it's in nursing practice council, where they can role-play situations that happen … The unit has to set the tone, or it has to be an expectation in the unit that conversations will happen … When those conversations happen and someone comes and complains that the conversation happens, you have … to listen and support that this conversation needed to happen.

236. CLABSI Learning From Defects Tool (doc file)
     www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/clabsi-learning-from-defects.docx
     April 01, 2022 - ) Hemodialysis Other: _____________________ Why did the CLABSI happen

237. CLABSI Learning From Defects Tool (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/clabsi-learning-from-defects.docx
     April 01, 2022 - ) Hemodialysis Other: _____________________ Why did the CLABSI happen

238. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46626/psn-pdf
     December 22, 2018 - What happened to my patient? An educational intervention to facilitate postdischarge patient follow-up. December 22, 2018 Narayana S, Rajkomar A, Harrison JD, et al. What Happened to My Patient? An Educational Intervention to Facilitate Postdischarge Patient Follow-Up. J Grad Med Educ. 2017;9(5):627-633. doi:10.430…

239. Appendix B17: Handout for Inservice #1, Why Falls Happen in Nursing Facilities | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb17.html
     December 01, 2017 - Care Resources Injuries Appendix B17: Handout for Inservice #1, Why Falls Happen … Quality Improvement Initiative for Nursing Facilities Appendix B17: Handout for Inservice #1, Why Falls Happen … created February 2010 Internet Citation: Appendix B17: Handout for Inservice #1, Why Falls Happen

240. Learning From Defects Through Sensemaking: Facilitator Notes | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-fac-notes.html
     December 01, 2017 - Say: A defect is anything you do not want to have happen again or ever have happen, even if it hasn … Why did it happen? How will you reduce the risk of it happening again? … Slide 21: Why Did It Happen? Ask: Why did the defect occur? … Slide 22: Why Did It Happen? Say: Make the whys visual. … Slide 23: Why Did It Happen? Say: Think about the culture.