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Total Results: 4,075 records

Showing results for "happen".

261. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/overview-cuspmvp-facguide.docx
     January 01, 2017 - SAY: A defect is anything that can happen clinically or operationally that you do not want to have happen … First ask, how did the defect happen?

262. In Conversation with…Thomas H. Gallagher, MD | PSNet
     psnet.ahrq.gov/perspective/conversation-withthomas-h-gallagher-md
     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 … Thus, these data do not necessarily speak to what will happen to liability if a physician's disclosure … We are going to do what it takes to make you better and make sure the same thing does not happen again

263. Disclosure of Medical Error | PSNet
     psnet.ahrq.gov/perspective/disclosure-medical-error
     January 01, 2009 - Thus, these data do not necessarily speak to what will happen to liability if a physician's disclosure … We are going to do what it takes to make you better and make sure the same thing does not happen again … 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

264. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42942/psn-pdf
     February 22, 2024 - elimination-emergency-department-medication-errors-due-estimated-weights https://psnet.ahrq.gov/issue/could-it-happen-here-learning-other-organizations-safety-errors

265. Ambulatory Surgery Center Survey on Patient Safety Culture: Composites and Items (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/resources/asc-items.pdf
     January 01, 2015 - We are good at changing processes to make sure the same patient safety problems don’t happen again. … Staff are told about patient safety problems that happen in this facility.

266. Quick Tips When Planning for Surgery (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patients-consumers/diagnosis-treatment/surgery/tips/tipsurgery.pdf
     June 02, 2025 - What will happen if I don’t have this operation? 7. Where can I get a second opinion?

267. Strategy 3: Bedside Shift Report (Tool 2) (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy3/Strat3_Tool_2_Nurse_Chklst_508.pdf
     June 02, 2025 - o “What do you want to happen during the next 12 hours?”

268. Root Cause Analysis | Digital Healthcare Research
     digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/root-cause-analysis
     January 01, 2023 - occurrence, and to develop means to prevent the issue from recurring or reduce the probability that it will happen

269. 019-Perioperative-Infection-Prevention-Strategies-Notes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-surgery/019-perioperative-infection-prevention-strategies-notes.docx
     April 01, 2025 - · Why did it happen? · How do we reduce the likelihood of this happening again? … Slide 32 Case Example: Why Did it Happen? SAY: So, why did it happen?

270. 019-Ss-Periop-Infection-Prevention-Fg (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/019-ss-periop-infection-prevention-fg.docx
     April 01, 2025 - · Why did it happen? · How do we reduce the likelihood of this happening again? … Slide 32 Case Example: Why Did it Happen? SAY: So, why did it happen?

271. Session 1 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mod3sess3.html
     October 01, 2014 - They have learned how to avoid those situations and, when they do happen, to fix them as well as they … A situation in which a care provider's actions are not well-intended may happen; that person may have … Sometimes, there is a situation that can be called "an accident waiting to happen." … Fixing "accidents waiting to happen."

272. Understand the Science of Safety for Perinatal Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-facilitator-guide.pdf
     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? … • Why did it happen? • How will you reduce the risk of recurrence? • How will you know it worked?

273. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33613/psn-pdf
     May 01, 2005 - How could such a terrible mistake happen to a team of highly qualified and dedicated individuals in … journey; the transition to an optimal culture of shared responsibility and accountability does not happen … have maintained the status quo, based on the mistaken premise that "mistakes like that could never happen

274. On O.R. Off? | PSNet
     psnet.ahrq.gov/web-mm/or
     August 22, 2013 - result of a complex system with multiple communication failures, which is how most medical mistakes happen … No one had the big picture of what was supposed to happen. … result of a complex system with multiple communication failures, which is how most medical mistakes happen … No one had the big picture of what was supposed to happen. … concern, and the promotion of situational awareness, where all the team members know what is going to happen

275. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866812/psn-pdf
     September 25, 2024 - the investigation or not, communicating to the patient what was learned so that the error will not happen

276. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33662/psn-pdf
     January 01, 2008 - Sometimes safety improvements are generated when bad things happen to good people. … The average size of a Tenet Hospital is about 150 beds, so these things happen infrequently. … then there would be, for example, the four things you or your unit can do, to make sure this doesn't happen … randomized controlled trial evidence that a particular safety intervention works just isn't going to happen

277. Communication Assessment Guide: Appendix 2 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/ap2.html
     August 01, 2022 - stable; her heart rate, blood pressure, and oxygen level are all in normal ranges, but something did happen

278. Video-Transcript-Spanish (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module3/video-transcript-spanish.docx
     June 02, 2025 - Unfortunately, things like this happen. … I hope that doesn´t happen to me. What should I do? ¿En serio? Espero que no me pase lo mismo. … It was an honest mistake, which won´t happen again. I´m sorry.

279. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47757/psn-pdf
     February 06, 2019 - Doctors make mistakes. A new documentary explores what happens when they do—and how to fix it. February 6, 2019 Park A. Time Magazine. January 24, 2019. https://psnet.ahrq.gov/issue/doctors-make-mistakes-new-documentary-explores-what-happens-when-they- do-and-how-fix-it This news article reports on the documentar…

280. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46506/psn-pdf
     October 11, 2017 - Getting Ahead of Harm Before It Happens: A Guide About Proactive Analysis for Improving Surgical Care Safety. October 11, 2017 Wiley K, Davies JM. Edmonton, AB: Canadian Patient Safety Institute; 2017. https://psnet.ahrq.gov/issue/getting-ahead-harm-it-happens-guide-about-proactive-analysis-improving- surgical-car…