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effectivehealthcare.ahrq.gov/sites/default/files/zikmund.pdf
December 26, 2012 - Absolute Probability
• Comparative Probability
• Incremental Probability
Sample Cognition:
• Might happen … Absolute Probability
• Comparative Probability1
• Incremental Probability
Sample Cognition:
• Might happen … to me.”
• “It is
more likely to happen to me.”
• “I am more likely to have this
happen to me … than to have that happen to me.”
• “I am a person who has
a higher
chance of
this happening … Need:
• Avoid Surprise and Regret
What Patients Care About:
• Care that this could
happen
Congruent
-
effectivehealthcare-admin.ahrq.gov/sites/default/files/zikmund.pdf
December 26, 2012 - Absolute Probability
• Comparative Probability
• Incremental Probability
Sample Cognition:
• Might happen … Absolute Probability
• Comparative Probability1
• Incremental Probability
Sample Cognition:
• Might happen … to me.”
• “It is
more likely to happen to me.”
• “I am more likely to have this
happen to me … than to have that happen to me.”
• “I am a person who has
a higher
chance of
this happening … Need:
• Avoid Surprise and Regret
What Patients Care About:
• Care that this could
happen
Congruent
-
psnet.ahrq.gov/issue/bad-things-can-happen-are-medical-students-aware-patient-centered-care-and-safety
July 06, 2022 - Study
Bad things can happen: are medical students aware of patient centered care … Bad things can happen: are medical students aware of patient centered care and safety? … Bad things can happen: are medical students aware of patient centered care and safety?
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/MO_Items-Composite_Measures.pdf
October 04, 2023 - Sometimes, Most of the time, Always, Does Not Apply or Don’t Know)
How often do the following things happen … This office is good at changing office processes to make sure the same problems don’t happen again. … Mistakes happen more than they should in this office. (negatively worded)
F4. … They overlook patient care mistakes that happen over and over. (negatively worded)
E3. … In your best estimate, how often did the following things happen in your medical office OVER THE PAST
-
psnet.ahrq.gov/node/39080/psn-pdf
November 04, 2009 - How could this happen?
November 4, 2009
Westfall SS; Mascia K. People. October 5, 2009. … https://psnet.ahrq.gov/issue/how-could-happen
This story discusses an instance of mistakenly implanted … https://psnet.ahrq.gov/issue/how-could-happen
-
psnet.ahrq.gov/issue/surgical-safety-does-not-happen-accident-learning-perioperative-near-miss-case-studies
August 04, 2021 - Commentary
Surgical safety does not happen by accident: learning from perioperative … Surgical safety does not happen by accident: learning from perioperative near miss case studies. … Surgical safety does not happen by accident: learning from perioperative near miss case studies.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/publications/files/sustainability-guideapa.pdf
January 01, 2009 - Who Should
Make This
Happen?
When Will
This
Happen? … What Other Information
Do I Need To Make This
Happen? … Who Should
Make This
Happen?
When Will
This
Happen? … What Other Information
Do I Need To Make This
Happen? … Who Should
Make This
Happen?
When Will
This
Happen?
-
digital.ahrq.gov/health-it-tools-and-resources/health-it-bibliography/nursing-informatics/evidence-based-practice-how
June 14, 2021 - Evidence-based practice: how nursing administration makes IT happen
As the voice of and advocate … 30 Issue: 3 Page Number: 291-4 Link: Evidence-based practice: how nursing administration makes IT happen
-
psnet.ahrq.gov/node/40815/psn-pdf
September 28, 2011 - Program encourages reporting accidents waiting to
happen: the Good Catch Awards. … https://psnet.ahrq.gov/issue/program-encourages-reporting-accidents-waiting-happen-good-catch-awards … https://psnet.ahrq.gov/issue/program-encourages-reporting-accidents-waiting-happen-good-catch-awards
-
psnet.ahrq.gov/issue/fatal-pca-adverse-events-continue-happenbetter-patient-monitoring-essential-prevent-harm
June 10, 2018 - Newspaper/Magazine Article
Fatal PCA adverse events continue to happen...better patient … Citation Text:
Fatal PCA adverse events continue to happen...better patient monitoring is essential … Cite
Citation
Citation Text:
Fatal PCA adverse events continue to happen
-
www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/resources/tools/implement/facility-action-plan.docx
January 01, 2018 - Steps
How will this happen? … Who will make this happen?
[Be specific for each task.] … What other information do I need to make this happen? … Steps
How will this happen? … What other information do I need to make this happen?
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/resources/tools/implement/facility-action-plan.docx
January 01, 2018 - Steps
How will this happen? … Who will make this happen?
[Be specific for each task.] … What other information do I need to make this happen? … Steps
How will this happen? … What other information do I need to make this happen?
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/action-plan-template.docx
April 01, 2022 - How will this happen? … [Be specific and include important steps to make the idea/activity happen.]
_________________________ … Who will make this happen?
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/024-ss-cusp-learning-from-defects.pptx
April 01, 2025 - Defects: Clinical or operational events or situations that you do not want to happen again
Examples of … Why did it happen?
How will you reduce the likelihood of this defect from happening again? … Program for MRSA Prevention | Surgical Services
Learning From Defects
11
Question Two
Why Did It Happen … MRSA Prevention | Surgical Services
Learning From Defects
Learning From Defects Process: Why Did It Happen … Why did it happen?
How will you reduce the likelihood of this defect happening again?
-
psnet.ahrq.gov/issue/preventing-lawsuits-coalition-pushes-apologies-and-cash-front-dealing-medical-errors-when
February 20, 2019 - Dealing with medical errors when they happen--instead of in court--can benefit doctors and patients, … Dealing with medical errors when they happen--instead of in court--can benefit doctors and patients, … Dealing with medical errors when they happen--instead of in court--can benefit doctors and patients,
-
pbrn.ahrq.gov/patient-safety/settings/hospital/candor/impguide/apd.html
February 01, 2017 - Steps
How will this happen? … [Be specific and include important steps to make the idea/activity happen.] … Who will make this happen? [Be specific for each task.] … What other information do I need to make this happen?
-
pcmh.ahrq.gov/patient-safety/settings/hospital/candor/impguide/apd.html
February 01, 2017 - Steps
How will this happen? … [Be specific and include important steps to make the idea/activity happen.] … Who will make this happen? [Be specific for each task.] … What other information do I need to make this happen?
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/guides/sustainability-guideapa.pdf
January 01, 2009 - Who Should
Make This
Happen?
When Will
This
Happen? … What Other Information
Do I Need To Make This
Happen? … Who Should
Make This
Happen?
When Will
This
Happen? … What Other Information
Do I Need To Make This
Happen? … Who Should
Make This
Happen?
When Will
This
Happen?
-
www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/management/huddles-pdsa-form.html
June 01, 2017 - Where will huddle happen? Default: In front of the visual management board
9. … Predict what will happen when the test is carried out (e.g., if we do “x,” “y” will happen)
Measures …
Predict what will happen … when the test is carried out (i.e., if we do “x,” “y” will happen)
Measures to compare prediction
-
www.ahrq.gov/hai/tools/mrsa-prevention/surgery/learning-from-defects.html
April 01, 2025 - According to CUSP, a defect is broadly defined as “Anything you do not want to happen again.” … Why did it happen? What will we do to reduce the risk of this happening again?