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psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp-0
March 27, 2024 - I foresee that that's what's going to happen in the world of data. … folks who put in the original wells or created the infrastructure, who at some level don't want that to happen … the fabric of life, instead of fighting them people would turn to improving them—and that that would happen
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psnet.ahrq.gov/issue/what-happens-medication-regimens-older-adults-during-and-after-acute-hospitalization
May 19, 2021 - Study
What happens to the medication regimens of older adults during and after an acute hospitalization?
Citation Text:
Harris CM, Sridharan A, Landis R, et al. What happens to the medication regimens of older adults during and after an acute hospitalization? J Patient Saf. 2013;9(3):15…
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psnet.ahrq.gov/perspective/conversation-ellen-deutsch-md-ms-facs-faap-fssh-cpps
December 14, 2022 - It was always a draft because as the day evolved, things would happen that changed that plan. … All patient care events happen in the context of other people and other parts of the system. … It’s the idea that we think that work—like providing healthcare—will happen a certain way, but when work … actually happens, people often have to make adjustments to make the work happen effectively and get … All these situations happen while considering the conditions, capabilities, and preferences of individual
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psnet.ahrq.gov/perspective/resilient-healthcare-and-safety-i-and-safety-ii-frameworks
December 14, 2022 - All these situations happen while considering the conditions, capabilities, and preferences of individual … It was always a draft because as the day evolved, things would happen that changed that plan. … All patient care events happen in the context of other people and other parts of the system. … It’s the idea that we think that work—like providing healthcare—will happen a certain way, but when work … actually happens, people often have to make adjustments to make the work happen effectively and get
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_audit_briefing_facnotes.docx
December 01, 2017 - with teammates, when people understand what that plan is, when they have a sense of what’s going to happen … Slide 6
Developing a Briefing Audit Tool
ASK:
How do you think briefings and debriefings should happen … ASK:
What is the worst thing that could happen, and what are we going to do about it if it did? … We know this is important, but it’s tough to make happen. … All of these steps happen before the case begins, or prior to incision.
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www.ahrq.gov/hai/tools/surgery/modules/implementation/audit-briefing-fac-notes.html
December 01, 2017 - with teammates, when people understand what that plan is, when they have a sense of what’s going to happen … Slide 7: Developing a Briefing Audit Tool
Ask:
How do you think briefings and debriefings should happen … Ask:
What is the worst thing that could happen, and what are we going to do about it if it did? … We know this is important, but it’s tough to make happen. … All of these steps happen before the case begins, or prior to incision.
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/management/huddles-comp-kit.html
June 01, 2017 - In ambulatory surgery centers (ASCs), huddles can happen once per day with each unit (e.g., the operating … Level 3: Daily huddles happen when the supervisor is not present. … What can you do to make the huddle happen every day?
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psnet.ahrq.gov/node/73302/psn-pdf
May 26, 2021 - How do we shift the thinking to the idea that these are harms that
may happen to the patient, be it … for bringing something forward that only makes the
organization better, but unfortunately that does happen … Why did this error happen?
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psnet.ahrq.gov/node/33875/psn-pdf
March 01, 2019 - And how can we make sure this
doesn't happen again? … And
that often doesn't happen, or it happens in a flurry of white coats being led around without getting
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www.ahrq.gov/sites/default/files/2024-12/moyer-report.pdf
January 01, 2024 - month but less than
1x/week
4
Frequent: Likely to occur immediately or
within a short period (may happen … times in 1 year)
Greater than 1x/year but less than
1x/month
3 Occasional: Probably will occur (may
happen … several times in 1 to 2 years)
Less than 2x/year
2 Uncommon: Possible to occur (may
happen sometime … in 2 to 5 years)
Once every 2 - 5 years
1 Remote: Unlikely to occur (may happen
sometime in 5 to
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/huddles/huddles-component-kit.docx
May 01, 2017 - In ambulatory surgery centers (ASCs), huddles can happen once per day with each unit (e.g., the operating … Level 3: Daily huddles happen when the supervisor is not present. … What can you do to make the huddle happen every day?
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www.ahrq.gov/ncepcr/tools/self-mgmt/what-script.html
February 01, 2016 - What is Self-Management Support? (Video Transcript)
Self-Management Support
For me self management support is helping the patient to play an active role in their healthcare and to become a partner with the nurse and physician team instead of the recipient of care.
Hello Ms. Mason. How are you doing today? W…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/McNeill.pdf
January 01, 2004 - Change
Dwight McNeill, Howard Holland, Kerm Henriksen
Abstract
This paper addresses how to make happen … practices and quality of care will indicate if the models provide useful
guidance in making change happen … different approaches for reducing patient
harm, increasing the Nation’s knowledge base, and making change happen … In general, the job of action production—i.e., making change happen through
implementation—is not done … the seemingly incongruent context of agriculture, provides very useful
guidance on how to make this happen
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/pf-engagement-fac-guide.html
July 01, 2023 - Medical providers are committed to caring for their patients; however, adverse events can happen.
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psnet.ahrq.gov/web-mm/mark-my-limb
February 10, 2015 - world's most sophisticated operating theaters and in the hands of highly trained surgeons—can such things happen … Or, in this case, almost happen? … Good systems do not just happen.
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mod1sess2.html
October 01, 2014 - Changes like this that happen suddenly might be related to their medication, or they may signal a stroke … But once you're familiar with daily patterns, you'll be aware of the things that happen often and those … Sometimes systems create "an accident waiting to happen."
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psnet.ahrq.gov/issue/patient-safety-10
May 01, 2023 - May 1, 2023
Program encourages reporting accidents waiting to happen: the Good Catch
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www.ahrq.gov/hai/cusp/toolkit/content-calls/how-to-spread.html
April 01, 2013 - And I’ll say, “Yes, I do,” because what is going to happen to you over time, what you can anticipate … notion here is primarily that you have to realize if you’re going to spread it, it may occasionally happen … Okay, so it could happen either way, but you need the support of management, generally, in order to be … So you want to make sure that it doesn’t happen to you by doing a little planning up front. … have many people on the line who are in the same position where they are pretty much making this thing happen
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/podcasts/Teamwork_in_QI_2012_02_01_Transcript.pdf
January 01, 2012 - Marjie Harbrecht
So really as I was saying before, this has to happen at every level. … So it has to happen in the practice level where
the team within the practices are really working well … It also has to happen with patients and their families. … healthy and prevent a lot of the things that we see now that really are avoidable and
don’t need to happen
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/item-sets/CG/administering_cg_narrative_items.pdf
June 01, 2021 - About the CAHPS Patient Narratives Elicitation Protocol
June 2021
Administering the CAHPS® Clinician &
Group Narrative Item Set
Introduction ......................................................................................................... 1
Placing the Narrative Items in the Survey ......................…