Results

Total Results: 3,974 records

Showing results for "happen".

341. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47061/psn-pdf
     July 25, 2018 - measuring-preventable-harm-helping-science-keep-pace-policy https://psnet.ahrq.gov/issue/adverse-outcomes-why-bad-things-happen-good-people

342. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47375/psn-pdf
     November 02, 2018 - ethical-duty-health-care-systems-address-interfacility-medical-error-discovery https://psnet.ahrq.gov/issue/could-it-happen-here-learning-other-organizations-safety-errors

343. AHRQ Slide Template-Regular
     www.ahrq.gov/sites/default/files/wysiwyg/takeheart/assessing/takeheart-summary-presentation.pptx
     April 26, 2023 - AHRQ Slide Template-Regular TAKEheart: AHRQ’s Initiative to Increase Patient Participation in Cardiac Rehabilitation What We Planned, What Happened, and What We Learned Michael Harrison and Dina Moss April 26, 2023 (Edited 5-25-23) Dina was COR and implementation lead; Michael was co-COR and evaluation/disseminati…

344. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/4es-early-mobility-facguide.docx
     January 01, 2017 - How can execute our plan and make this happen? … early mobility at our hospital, change the culture, and provide the necessary resources to make it happen … A defect is anything you do not want to happen again. Ask, “What happened and why did it happen?”

345. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/847060/psn-pdf
     January 01, 2001 - The Emperor’s New Clothes: Or Whatever Happened To “Human Error”? January 1, 2001 Hollnagel E, Amalberti R. Chapter In: Dekker SWA, ed.  Proceedings of the 4th International Workshop on Human Error, Safety and Systems Development. Linköping Sweden: Linköping University; 2001. https://psnet.ahrq.gov/issu…

346. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44327/psn-pdf
     August 26, 2015 - Safely Home: What Happens When People Leave Hospital Care Settings? August 26, 2015 London, UK: Healthwatch England; July 2015. https://psnet.ahrq.gov/issue/safely-home-what-happens-when-people-leave-hospital-care-settings Discharges are vulnerable periods for patients, often due to miscommunication, delays, and l…

347. Ambulatory Procedure/Surgery Center Survey on Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/asc-survey-english.pdf
     June 02, 2025 - Staff are told about patient safety problems that happen in this facility ......................... … We are good at changing processes to make sure the same patient safety problems don’t happen again.

348. 1d2 Workflow Assessment Guide (doc file)
     digital.ahrq.gov/sites/default/files/docs/workflowtoolkit/WorkflowInterviewGuide.doc
     December 18, 2021 - 1d2 Workflow Assessment Guide 1d2 Workflow Assessment Guide CFMC Staff Use Only (this box) Individuals interviewed: Workflow Assessors: Workflow Assessment date: Number/type of providers observed: General Information Clinic Name: Total number of exam rooms: Number of patients typica…

349. Learning-Antibiotic-Adverse-Events-Form (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/learning-antibiotic-adverse-events-form.docx
     November 01, 2019 - or situation involving the prescription or administration of antibiotics that you would not want to happen

350. Coaching-Facnotes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/coaching/coaching-facnotes.docx
     May 01, 2017 - Can you help me understand why that didn’t happen? … If something harmful to the patient can be avoided, the coach should say something and not let it happen

351. Decolonization Strategies
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/012-ss-decolonization-strategies.pptx
     April 01, 2025 - Why did it happen? How to reduce the likelihood of this defect from happening again? … Inconsistent use of mupirocin nasal decolonization Inconsistent screening of patients for MRSA Why did it happen

352. Transitioning to the SOPS™ Hospital Survey Version 2.0: What’s Different and What To Expect, Part II: Appendixes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hsops2-pt2_transition_apx.pdf
     September 01, 2019 - and Communication About Error 68% 65% 3% Major wording change We are informed about errors that happen … (C1) We are informed about errors that happen in this unit. … ------------------------------------- My supervisor/manager overlooks patient safety problems that happen … (C1) We are informed about errors that happen in this unit. … (C3) 66% 66% 0% +/- 3% [-3% to 3%] No change When errors happen in this unit, we discuss ways

353. Supplemental Items for the CAHPS Clinician & Group Child Survey 3.0/3.1: Narrative Comments | Agency for Healthcare Research and Quality
     www.ahrq.gov/cahps/surveys-guidance/item-sets/cg/suppl-narrative-items-cg-survey30-child.html
     August 01, 2021 - Supplemental Items for the CAHPS Clinician & Group Child Survey 3.0/3.1: Narrative Comments Population version: Child Learn about the CAHPS Patient Narrative Item Sets . Placing the items in the survey: Insert these supplemental items before the "About Your Child and You" section of the survey. Int…

354. Identifying Adverse Events Not Present on Admission: Can We Do It? | PSNet
     psnet.ahrq.gov/perspective/identifying-adverse-events-not-present-admission-can-we-do-it
     October 01, 2008 - If you are going to promulgate a policy that either publicly reports adverse events that happen in hospitals … to be sure that the hospital is not being blamed, for lack of a better word, for things that didn't happen … Sometimes patients are sent to us because they've had bad things happen—they're very ill and it's our … That in fact, hospitals should be paying for things that shouldn't happen, and that this type of policy … DRG-like system where we will pay for a given diagnosis, I think it is inevitable that when adverse events happen

355. Drug error at Eskenazi Hospital killed prominent cancer researcher. Here's how it happened. | PSNet
     psnet.ahrq.gov/issue/drug-error-eskenazi-hospital-killed-prominent-cancer-researcher-heres-how-it-happened
     September 09, 2015 - Newspaper/Magazine Article Drug error at Eskenazi Hospital killed prominent cancer researcher. Here's how it happened. Citation Text: Drug error at Eskenazi Hospital killed prominent cancer researcher. Here's how it happened. Evans T. Indianapolis Star. October 30, 2020. Copy Citatio…

356. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34691/psn-pdf
     May 18, 2016 - human errors will occur and that are designed to minimize their occurrence and absorb them when they happen

357. The Power of Patient Stories for Improving the Patient Experience webcast - Nembhard (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/patient-narratives-webinar-quality.pdf
     June 02, 2025 - The Power of Patient Stories for Improving the Patient Experience webcast - Nembhard Using Narratives for Quality Improvement Ingrid Nembhard, PhD, MS Fishman Family President’s Distinguished Associate Professor of Health Care Management Disclosures This work was funded by the Agency for Healthcare Research a…

358. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43779/psn-pdf
     May 28, 2015 - debriefing in the emergency department, this commentary outlines how to determine when a debrief should happen

359. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33867/psn-pdf
     October 01, 2018 - We thought for sure that many errors that might have happened in the past wouldn't happen. … We have some really dangerous errors that happen. … A lot of that can happen at the counseling stage, where there's some communication between the pharmacist … And what is the pharmacy chain doing to make sure that something like that doesn't happen?" … and many vendors are making it available now for the first time, called CancelRx, but that doesn't happen

360. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866622/psn-pdf
     August 28, 2024 - Safety-I uses a traditional, reactive, and failure-focused approach to managing safety events when they happen … The assumption here is that the system is not complex, is inherently safe, and that bad things only happen … We should not ignore those instances when they happen, but we should also really be mindful that the