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www.ahrq.gov/cahps/quality-improvement/improvement-guide/5-determining-focus/section5part2.html
January 01, 2020 - #3): The physicians in the practice are not willing to work on Saturdays, and many of them are not always … However, front-line caregivers sometimes become so accustomed to working in a "broken" system that they … Try to act as if you have never been there before. Follow the signs. … , usually over dinner, and participation on one committee. … members of practice improvement teams brings the patient voice and perspective directly into the hard and sometimes
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/handouts.html
September 01, 2017 - I know this is an important aspect of care for our residents but we have never developed a policy and … Sometimes results require us to call when we receive them. … Evening Nursing Supervisor: The call is usually made by the charge nurse or nursing supervisor on the … Note: Residents and/or their families are always invited to care plan meetings but don’t always choose … We’ve had our EMR for several years, but I’ve never been so impressed with the value of the information
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospital-user-guide.pdf
July 01, 2018 - Always
1. … Question Never
Rarely
Some-
times
Most of
the time
Always
1. … Feedback & Communication About Error
(Never, Rarely, Sometimes, Most of the time, Always)
C1. … Communication Openness
(Never, Rarely, Sometimes, Most of the time, Always)
C2. … Frequency of Events Reported
(Never, Rarely, Sometimes, Most of the time, Always)
D1.
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/handouts.html
December 01, 2017 - We only address those residents who we think have ulcers that will never heal due to the resident’s overall … We usually focus on residents with changes in care plans. … Pressure ulcers are always on the agenda; sometimes we have QAA projects related more to prevention. … Nurse Manager C: So it is usually the nurse manager and a physician who make rounds together but sometimes … Usually done weekly.
Charge nurse/nurse manager and CNAs.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-implementation-handouts.docx
July 01, 2016 - We only address those residents who we think have ulcers that will never heal due to the resident’s overall … We usually focus on residents with changes in care plans. … Pressure ulcers are always on the agenda; sometimes we have QAA projects related more to prevention. … Nurse Manager C: So it is usually the nurse manager and a physician who make rounds together but sometimes … Usually done weekly.
Charge nurse/nurse manager and CNAs.
-
www.ahrq.gov/hai/cusp/toolkit/content-calls/engagement.html
April 01, 2013 - infections were high and we didn’t have all the equipment that we needed, I would make a conscious, perhaps sometimes … That would never happen. Why? Because it’s not change that people fear. It’s loss. … Now sometimes they say, “Hey, we scratched our head. We don’t know why we have this infection. … And I always do it alone and in a safe space, always alone and in a safe space. … This culture’s never going to change.” That’s not a very constructive thing to do.
-
psnet.ahrq.gov/node/33865/psn-pdf
September 01, 2018 - problem in that about one in a thousand shunters
were dying every year on the railway, and they were usually … We try to develop quick, sensible fixes, but we're never going to get to the
fundamental problems that … possible to do that" or "I can't see how we could make that work," patients have a different perspective
sometimes … Because it will always be
unpredictable whether a patient can be involved in their safety or not, by … does require a different culture of communication and an acknowledgement of uncertainty and that
sometimes
-
www.ahrq.gov/sites/default/files/2024-07/carroll-report.pdf
January 01, 2024 - Sometimes a woman can be
having a baby and be having seizures. … They never see the doctor. … We have a good life here and we don’t have any problem and always
[we] thinking about back in Africa … I
never heard anybody talking about cancer.
012
Some people don't know what the word means or sometimes … Routine check-ups were usually only mentioned in the context of prenatal
care.
-
psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
September 28, 2022 - Or when someone has diabetes that’s out of control with an elevated hemoglobin A1c, or when someone never … Similarly, some people get plugged into primary care settings but would never go to a mental healthcare … Providers that get MPHs as part of their education have a good understanding usually of population health … JW: Patient safety is always forefront in primary care practices. … There’s other times when a patient gets a test, and whether it’s normal or abnormal, the results never
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Wears_75.pdf
May 27, 2008 - Accidents usually occur when factors have been forgotten or not accounted for in the software or
system … However, changes are not always planned, so periodic audits and performance monitoring are
required … Further Considerations
Sometimes an assumption is made that if software has been executing safely in … IT must be tailored for the larger system in which it will
operate (which always has unique features … The alternative proposed in this article is to begin by envisioning the
states the system should never
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/imp-handouts.pdf
June 02, 2025 - I know this is an important aspect of care for our
residents but we have never developed a policy and … Sometimes
results require us to call when we receive them. … Evening Nursing Supervisor: The call is usually made by the charge nurse or nursing
supervisor on the … Note: Residents and/or their
families are always invited to
care plan meetings but don’t
always choose … We’ve had our EMR for several years, but I’ve
never been so impressed with the value of the information
-
psnet.ahrq.gov/web-mm/intraoperative-awareness-during-rhinoplasty
January 29, 2021 - Memory of this type of event after the operation is uncommon because patients usually start moving in … The clinical signs of depth of anesthesia should therefore always be assessed, and processed EEG monitors … Sometimes a confused patient receives a spinal anesthetic during surgery for a hip fracture. … Production pressure in the operating room should never lead clinicians to deliver suboptimal care to … Arterial Thrombosis
June 28, 2023
WebM&M Cases
Always
-
digital.ahrq.gov/sites/default/files/docs/2010-02-24%20Transitions%20In%20Care%20(4).pdf
January 01, 2010 - .
•
These care failures allow, and sometimes cause,
the clinical deterioration that leads to … 10% 16%
“I prefer Louise, she’s
better than a doctor, she
explains more, and
doctors are always … “It was just like a nurse,
actually better, because
sometimes a nurse just
gives you the paper … • We have momentum and allies as never
before.
• And a word from a sage.
-
digital.ahrq.gov/sites/default/files/docs/publication/r18hs017855-friedman-final-report-2013.pdf
January 01, 2013 - This proved to be somewhat effective and
the TLC-C utilization improved but it never piqued to the point … A person who had used this module
several times said that he liked it because he usually had several … possible that the TLC-C’s alerts
were chucked together with the other alerts. 2) Clinicians are not always … The vulnerable patients who were recruited for this study usually have an array of socio-
economic and … The dissemination of these technologies,
however, has not always been a smooth one.
-
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.
-
psnet.ahrq.gov/node/33678/psn-pdf
January 01, 2009 - Thomas Gallagher: I've always been interested in difficult conversations between doctors and
patients … Lots of clinicians really struggle with
the concern that sometimes disclosure may not be beneficial … The vast majority
of patients who are injured by their care never sue. … Eight states require the disclosure of
some adverse events to patients—usually the most serious of these … But that follow-up conversation usually is an opportunity to again explain what happened.
-
psnet.ahrq.gov/perspective/conversation-withjames-p-bagian-md
September 01, 2006 - My father used to always tease me about it. … Well, I always say that the person who thinks it can never happen to them is the most dangerous person … Whereas, in the private sector, that isn't always the case. … Had we not had our central patient safety information system, we never could have figured that out because … By allowing each VISN (and usually each facility) to decide how it should meet its performance targets
-
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
-
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
-
psnet.ahrq.gov/perspective/conversation-rebecca-lawton-phd
March 24, 2025 - problem in that about one in a thousand shunters were dying every year on the railway, and they were usually … We try to develop quick, sensible fixes, but we're never going to get to the fundamental problems that … possible to do that" or "I can't see how we could make that work," patients have a different perspective sometimes … Because it will always be unpredictable whether a patient can be involved in their safety or not, by … safety does require a different culture of communication and an acknowledgement of uncertainty and that sometimes