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www.ahrq.gov/sites/default/files/publications/files/ltcmodule3.pdf
June 01, 2012 - Sometimes, there is a situation that can
be called “an accident waiting to happen.” … While that’s sometimes easier said than
7
NOTES done – especially on sensitive matters that we think … To help prevent
falls, never leave a resident alone during a transfer (bed to chair, wheelchair
to … You should always alert the attending
professional (whether a licensed nurse, nurse practitioner, or … Risk factors are always present. We all have risk factors for falls.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/patient-family-centered-care-transcript.doc
April 09, 2013 - You just slipped in a Foley because it was easier for us; it was easier for us, never giving a thought … look at slide 16, real quickly, a graph you've seen before that looks at the translation errors that sometimes … And they leaned into my bed and they looked at the door handle and they said, 'I never noticed that. … Sometimes it's the stories of care that reflect the culture of your organization, and you know as well … And she is always very passionate about what she does and always makes us feel welcome and displays such
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www.ahrq.gov/hai/cauti-tools/archived-webinars/patient-family-centered-care-transcript.html
December 01, 2017 - You just slipped in a Foley because it was easier for us; it was easier for us, never giving a thought … look at slide 16, real quickly, a graph you've seen before that looks at the translation errors that sometimes … And they leaned into my bed and they looked at the door handle and they said, 'I never noticed that. … Sometimes it's the stories of care that reflect the culture of your organization, and you know as well … And she is always very passionate about what she does and always makes us feel welcome and displays such
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/cauti-sustainability-transcript.docx
January 01, 2014 - We never want to cause harm when someone comes in to the hospital. … Change requires respect and when you think about how you've always done things and how you were taught … People are a part of it, but usually it's a process. … If you fix the process, you usually fix the problem. … Use data to generate awareness, never to inflame.
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www.ahrq.gov/hai/cauti-tools/archived-webinars/cauti-sustainability-transcript.html
December 01, 2017 - We never want to cause harm when someone comes in to the hospital. … Change requires respect and when you think about how you've always done things and how you were taught … People are a part of it, but usually it's a process. … If you fix the process, you usually fix the problem. … Use data to generate awareness, never to inflame.
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www.ahrq.gov/sites/default/files/2024-01/friese-report.pdf
January 01, 2024 - Patients rated the frequency of their nausea, vomiting, diarrhea,
and pain (1 = never, 5 = almost constantly … Preparation usually entailed looking at the next day’s scheduled patients to assess
laboratory values … “I think another challenge is sometimes trying to figure out what’s on the doctor’s mind. … That doesn’t always happen, and we find ourselves at the last-minute standing in front
of a patient … As our findings suggest, plans of care are not always up to date on the day of infusion
appointments
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www.ahrq.gov/sites/default/files/2024-01/landrigan-report.pdf
January 01, 2024 - Adherence was
assessed on a five-point frequency scale (never, rarely, sometimes, usually, always), … with
responses reported as the percentage in which responses were usually or always adhering to
all … Reported as percentage of observed handoffs usually or always adhering
to all five elements. … Reported as
percentage of observed handoffs usually or always adhering to all five elements. … Reported as percentage of written
handoffs usually or always adhering to all five elements.
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www.ahrq.gov/sites/default/files/2025-03/mcfarland-report.pdf
January 01, 2025 - though they assigned high priority to patient safety in terms of their
beliefs, best practices are not always … Communication is sometimes inconsistent, fragmented, or (unintentionally) unclear. … they assigned a high priority to patient safety in terms of their beliefs, best practices are
not always … (circle all that apply)
I’ve never heard of it.
I’ve heard the name.
I’ve seen the website. … Usually, more specifics are
provided (e.g., who oversees whom and when, who contacts who in an
emergency
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www.ahrq.gov/sites/default/files/2024-01/thomas2-report.pdf
January 01, 2024 - during direct observation of an event in real time.
5
Observability Rating Scale
We could not always … The frequency rating is usually a 3 or 4. … The attending may never
come, but the threat (understaffing) could still be managed. … In other situations, practices among
physicians differed, sometimes substantially. … They show that
Information Sharing, Inquiry, Vigilance, and Workload Management were always observable
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/20150917/introducing_the_new_cahps_c&g_survey3.0.pdf
September 01, 2015 - Sometimes, it seems like your computer freezes during the presentations and you can hit your F5 button … I find the need sometimes to do that. … In other words, if
they’re asking a question “never,” “sometimes,” “usually,” “always,” then “always … I think that one’s always concerned about recall. … I mean it never is a perfect match because we’re dealing different kinds of data for sampling.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/003-clabsi-prevention-webinar-fg.docx
October 01, 2024 - Central lines are usually inserted by physicians, nurse practitioners, or physician assistants. … This is well known, but sometimes forgotten. … Slide 19
Maximal Sterile Barrier Precautions
SAY:
Maximal sterile barrier precautions must always … This is sometimes referred to as “scrubbing the hub.” … Ensure that a new swab is used for each hub; swabs should never be reused.
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www.ahrq.gov/hai/cauti-tools/archived-webinars/breaking-down-barriers-transcript.html
December 01, 2017 - In some places, catheters are inserted by techs and not licensed providers, so we can always require … I know HRAT has spent a lot of time and energy on this, but it's always worth repeating, I think, to … may not even be aware yourself that aseptic technique was violated, and off the patient goes and you never … It's a tube going into a natural orifice, usually there isn't the blood, the spurting all of that sort … They felt as if sometimes they didn't insert Foleys all the time.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/breaking-down-barriers-transcript.docx
May 12, 2015 - In some places, catheters are inserted by techs and not licensed providers, so we can always require … I know HRAT has spent a lot of time and energy on this, but it's always worth repeating, I think, to … may not even be aware yourself that aseptic technique was violated, and off the patient goes and you never … It's a tube going into a natural orifice, usually there isn't the blood, the spurting all of that sort … They felt as if sometimes they didn't insert Foleys all the time.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Kizer2.pdf
December 01, 2000 - other entities have enacted
legislation or taken administrative action to require reporting of these “never … of a highly
complex and imperfect health care delivery system, in which individual minor
mishaps sometimes … occur—what has been commonly referred to as the “never
events”—in early 2002.4
Methods
About the … To qualify for this core list of serious reportable events, an event had to be
unambiguous, usually … Requiring that an event be usually preventable recognizes that some of these
events are not always avoidable
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/20160413/hp-survey-strategies-webcast-transcript.pdf
April 01, 2016 - And that’s usually the wrong thing to do. … ,” “sometimes,” “usually” or
“always.” … What we do, is when we get a “never” or “sometimes” response, then we ask the consumer why. … And so we always anticipate that our members have many needs and we’ll always ask, “Is
there anything … That’s never
been a concern.
Susan Edgman-Levitan
Okay.
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www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-21-leadership.pdf
September 01, 2015 - Your ability to stay in regular communication
with practice leadership is critical and should usually … While usually
not effective in the beginning, once of the respondent has identified some new ideas, … Rob: I have to admit, I’ve never created a timeline before.
Boss: Thanks for being forthright. … Sometimes it’s helpful to work backwards
from the date of the event. … I’ve always appreciated your creativity.
Legitimation This would be hard for anyone.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/resources/guides/guide-infection-prevention.pdf
March 01, 2017 - Sometimes residents
have germs inside them
but they don’t get sick. … Respiratory illnesses often result in hospital stays—and sometimes even death. … The
following are unsafe practices and should never be done:
▪ Reusing single-use syringes and needles … outbreak occurs when there are more cases of an infectious disease in a designated
population than usually … Surveys are generally not
scheduled in advance, so it’s
important to always be
prepared.
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/20141022_cg/lessons_from_top-performing_medical_practices_CG-CAHPS_transcript.pdf
October 01, 2014 - It does get a little tricky sometimes with insurance issues. … put their name and contact info in case
they wanted to speak to someone from the practice, which was usually … This was
something we never had to deal with. … Always put the patient first. Empower the
patient. … But she always had a
positive attitude.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/fallspximpl-handouts.docx
June 02, 2025 - Sometimes when residents fall, they can never walk again. … We don’t always gain interdisciplinary input regarding fall risk interventions and we don’t always communicate … Nurse Manager A: I agree with you but I also don’t think that we always consider the medication regimen … could refer to it while conducting her record reviews and then leave recommendations for us as she usually … Sometimes the solutions are simple.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/educational-bundles/communication-and-teamwork/communication-strategies.pptx
September 01, 2016 - Times of observations and interventions should always be noted in the resident's record, and residents … Personalities—Sometimes it is difficult to communicate with particular individuals. … This overcomes our natural tendency to believe that the medical team leader or members must always know … Stopping the line is an action that should never be taken lightly and requires immediate cessation of