-
www.ahrq.gov/sops/international/medical-office/translators.html
January 01, 2010 - in the past 12 months, Does Not Apply or Don't Know)
The following items describe things that can happen … In your best estimate, how often did the following things happen in your medical office OVER THE PAST … They overlook patient care mistakes that happen over and over. … 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.
-
www.ahrq.gov/hai/cauti-tools/guides/sustainability-guideapa.html
October 01, 2015 - Plan for Sustainability
Need or Interest
Idea or Activity
Tools To Use
How Will This Happen … Who Should Make This Happen?
When Will This Happen? … What Other Information Do I Need To Make This Happen?
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/023-ss-cusp-learning-from-defects-fg.docx
April 01, 2025 - Another way to describe a defect is Anything that you do not want to happen again. … Why did it happen?
3. How will you reduce the likelihood of this defect happening again?
4. … Slide 11
Question Two—Why Did It Happen? … Slide 12
Learning From Defects Process: Why Did It Happen? … · Why did it happen?
· How will you reduce the likelihood of this defect happening again?
-
www.ahrq.gov/hai/tools/mrsa-prevention/surgery/premortem-assessment.html
April 01, 2025 - What if there was a magic telescope that could look into the future and let you see what is going to happen
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursing-home-survey-items-composite-english.pdf
September 01, 2024 - Sometimes, Most of the time, Always, Does Not Apply or Don’t Know)
How often do the following things happen … Sometimes, Most of the time, Always, Does Not Apply or Don’t Know)
How often do the following things happen … Sometimes, Most of the time, Always, Does Not Apply or Don’t Know)
How often do the following things happen … This nursing home lets the same mistakes happen again and again. (negatively worded)
D4.
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hsops-items-composites.pdf
June 02, 2025 - My supervisor/manager overlooks patient safety problems that happen over and over. … It is just by chance that more serious mistakes don't happen around here. (negatively worded)
A17. … We are informed about errors that happen in this unit.
C5.
-
www.ahrq.gov/evidencenow/heart-health/aspirin/stroke.html
September 01, 2018 - Resource description: This patient education booklet explains how heart attack and stroke happen, and
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/004-cusp-learning-from-defects.docx
October 01, 2024 - Why did it happen?
3. How will you reduce the likelihood of this defect happening again?
4. … Slide 11
Why Did It Happen? … Slide 12
LFD Process: Why Did It Happen? … Defects are clinical or operational events that you do not want to happen again. … · Why did it happen?
· How will you reduce the likelihood of this defect happening again?
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/clabsi-learning-from-defects_revised.docx
April 01, 2022 - ) Hemodialysis Other: _____________________
Why did the CLABSI happen
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb7.html
December 01, 2017 - Improvement Initiative for Nursing Facilities
Appendix B13: Pre and Posttests for Inservice #1, Why Falls Happen
-
www.ahrq.gov/patient-safety/settings/hospital/candor/modules.html
August 01, 2022 - Module 7: Resolution
Module 8: Organizational Learning and Sustainability
“We realize mistakes happen … Harms such as hospital-acquired infections or medication errors can happen during any stage of care.
-
digital.ahrq.gov/sites/default/files/docs/workflowtoolkit/SurveyOnPatientSafetyCulture.doc
January 01, 2008 - SECTION A: List of Patient Safety and Quality Issues
The following items describe things that can happen … In your best estimate, how often did the following things happen in your medical office OVER THE PAST … They overlook patient care mistakes that happen over and over
(1
(2
(3
(4
(5
(9
3. … Mistakes happen more than they should in this office
(1
(2
(3
(4
(5
(9
4. … This office is good at changing office processes to make sure the same problems don’t happen again
-
www.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/chapter1.html
August 01, 2022 - What caused the patient safety event to happen?
Where did the patient safety event happen?
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/tools/applying-cusp/learn_from_defects.docx
December 01, 2017 - Why did it happen? … Why did it happen?
Investigate your care delivery system. … Why did it happen? … Why did it happen? … Why did it happen?
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cauti-learning-from-defects-revised.docx
April 01, 2022 - (Circle): Yes No
Why did the CAUTI happen?
-
www.ahrq.gov/hai/tools/surgery/modules/sustainability/learn-from-defects-slides.html
December 01, 2017 - Slide 6: What Is a Defect
Anything you do not want to happen again. … (From view of person involved)
Why did it happen? … Slide 12: Why Did It Happen?
Critical to include adaptive teamwork concerns.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects_facnotes.docx
December 01, 2017 - Does the same fix happen for all patients, all caregivers, and all shifts? … SAY:
A defect is anything you do not want to have happen again or ever have happen, even if it hasn’t … Slide 20
Why Did It Happen?
ASK:
Why did the defect occur? … Slide 21
Why Did It Happen?
SAY:
Make the whys visual. … Slide 22
Why Did It Happen?
SAY:
Think about the culture.
-
www.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-fac-notes.html
December 01, 2017 - Say:
A defect is anything you do not want to have happen again or ever have happen, even if it hasn … Why did it happen?
How will you reduce the risk of it happening again? … Slide 21: Why Did It Happen?
Ask:
Why did the defect occur? … Slide 22: Why Did It Happen?
Say:
Make the whys visual. … Slide 23: Why Did It Happen?
Say:
Think about the culture.
-
www.ahrq.gov/sops/international/hospital/translators-version-2.html
October 01, 2024 - (negatively worded)
More about this item: When patient safety problems happen, this unit does not … do anything to ensure the problem does not happen again.
4. … negatively worded)
More about this item: Staff feel like they are unfairly blamed when mistakes happen … We are informed about errors that happen in this unit.
C2. … When errors happen in this unit, we discuss ways to prevent them from happening again.
C3.
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/clabsi-learning-from-defects-revised.pdf
April 01, 2022 - administration
Total parenteral nutrition (TPN) Hemodialysis Other: _____________________
Why did the CLABSI happen