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Total Results: 4,075 records

Showing results for "happen".

  1. Understand the Science of Safety | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/cusp/modules/understand/science-safety-notes.html
    July 01, 2018 - How Can These Errors Happen? Slide 6. The Science of Safety Slide 7. … Return to Contents   Slide 5: How Can These Errors Happen? … 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?

  2. 110-Ss-Lfd-Sample (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/110-ss-lfd-sample.docx
    April 01, 2025 - A defect is any clinical or operational event or situation that you would not want to happen again. … Why Did It Happen? Below is a framework to help you review and evaluate your case.

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867653/psn-pdf
    February 26, 2025 - “Why did it happen?” “What are we doing to keep it from happening again?”

  4. Learning from Patient Narratives Through Innovative Feedback Reporting Methods Webcast - Welcome from AHRQ (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/learning_pt_narratives_053123-ginsberg.pdf
    June 02, 2025 - surveys measure experience: ► What happened to the patient in the care encounter, or how often did it happen

  5. Narrative Items for the CAHPS Clinician & Group Visit Survey 4.0 (beta) | Agency for Healthcare Research and Quality

    www.ahrq.gov/cahps/surveys-guidance/item-sets/cg/suppl-narrative-items-cg-survey40-adult.html
    July 01, 2021 - Narrative Items for the CAHPS Clinician & Group Visit Survey 4.0 (beta) These supplemental items are designed to be used with the CAHPS Clinician & Group Visit Survey 4.0 (beta). Learn about the CAHPS Patient Narrative Item Sets . Learn about the Clinician & Group Visit Survey 4.0 (beta) . Placing …

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40194/psn-pdf
    June 20, 2011 - What happens when things go wrong? June 20, 2011 Brandom BW, Callahan P, Micalizzi DA. What happens when things go wrong? Paediatr Anaesth. 2011;21(7):730-6. doi:10.1111/j.1460-9592.2010.03513.x. https://psnet.ahrq.gov/issue/what-happens-when-things-go-wrong This commentary reveals a personal story of loss and dis…

  7. In Conversation with... Regina Hoffman about Building Capacity for Patient Safety | PSNet

    psnet.ahrq.gov/perspective/conversation-regina-hoffman-about-building-capacity-patient-safety
    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

  8. Building Capacity for Patient Safety | PSNet

    psnet.ahrq.gov/perspective/building-capacity-patient-safety
    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

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33651/psn-pdf
    June 01, 2007 - RW: When you send out a safety alert, would it be because you've seen this thing happen once or because … know that they're very earnest in identifying reportable events and wanting to understand why they happen … across states would also be a real leap forward in terms of what we could learn about why these events happen … One thing that we've learned is that there are a lot of reasons why these events happen and why they

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74276/psn-pdf
    January 19, 2022 - guideline-prevention-unintentionally-retained-surgical-items Retained surgical items (RSI) are a never event, yet they continue to happen

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50827/psn-pdf
    January 22, 2020 - High reliability organizations consistently examine what goes wrong and remain aware that failure can happen

  12. 103-How-To-Integrate-Cusp-Approach-Periop-Fg (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/103-how-to-integrate-cusp-approach-periop-fg.docx
    April 01, 2025 - A defect is defined as anything “you do not want to happen again.” … What happened, why did it happen using system lenses, what could you do to reduce the risk of it happening … An effective CUSP team knows mistakes happen and is committed to being vigilant to prevent them—and when

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867085/psn-pdf
    November 06, 2024 - A WebM&M highlights errors that can happen when medication kits are not standardized and are poorly

  14. Strategy 3: Nurse Bedside Shift Report (Tool 1) (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy3/Strat3_Tool_1_BSR_Broch_508.docx
    June 02, 2025 - If nurse bedside shift report does not happen, call the nurse manager at [insert phone number].

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34008/psn-pdf
    March 17, 2011 - They encourage doctors and their insurers to be honest when mistakes happen, offer apologies, and provide

  16. Implementation Guide Appendix J Coaching Tool Instructions and Observation Tool With Coaching Section (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/implementation-guide/appendix-j.pdf
    June 02, 2025 - Implementation Guide Appendix J Coaching Tool Instructions and Observation Tool With Coaching Section AHRQ Safety Program for Ambulatory Surgery Appendix J. Coaching Tool Instructions and Observation Tool With Coaching Section After using the observation tool to collect information regarding the processes perfor…

  17. Blackbox: A Multidisciplinary Team-Based Framework for HIT Error Pattern Detection - Final Report | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/context-critical-understanding-when-and-why-electronic-health-record-related/final-report
    January 01, 2023 - Context is Critical: Understanding When and Why Electronic Health Record-Related Safety Hazards Happen

  18. Appendix J. Coaching Tool Instructions and Observation Tool With Coaching Section - Implementation Guide | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/implementation-guide/app-j.html
    May 01, 2017 - Appendix J. Coaching Tool Instructions and Observation Tool With Coaching Section - Implementation Guide After using the observation tool to collect information regarding the processes performed in the operating room or procedure room, use the coaching tool to coach the team on what it is doing well and how it …

  19. Supplemental Items for the CAHPS Child Hospital Survey: Narrative Comments | Agency for Healthcare Research and Quality

    www.ahrq.gov/cahps/surveys-guidance/item-sets/ch/suppl-narrative-items-child-hospital-survey.html
    November 01, 2023 - Supplemental Items for the CAHPS Child Hospital Survey: Narrative Comments Population version: Child Learn about: CAHPS Patient Narrative Item Sets CAHPS Child Hospital Narrative Item Set   Placing the items in the survey: Insert these supplemental items before the "About You" section of the sur…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39489/psn-pdf
    June 11, 2010 - What happens between visits? Adverse and potential adverse events among a low-income, urban, ambulatory population with diabetes. June 11, 2010 Sarkar U, Handley MA, Gupta R, et al. What happens between visits? Adverse and potential adverse events among a low-income, urban, ambulatory population with diabetes. Qua…
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