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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/improving/improving-facnotes.docx
May 01, 2017 - A debriefing that never occurs cannot benefit subsequent patients. … Team members should never memorize the checklist. … Sometimes an operation is different from the one initially planned. … These are usually the most difficult items for teams to perform consistently, and they are the most commonly … Always have an implementation team member in the room to collect feedback about changes.
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www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/nursing-home/nursinghome-users-guide.pdf
April 01, 2022 - items use 5-point agreement scales (“Strongly disagree” to “Strongly agree”) or
frequency scales (“Never … ” to “Always”) and include a “Does not apply or Don’t know” response
option. … If you usually administer paper surveys, it might
be better to continue with that data collection method … Agree or Most of the time 4
Neither agree nor disagree or Sometimes 3
Disagree or Rarely 2
Strongly … The midpoints of
the scales are reported as a separate category (Neither Agree nor Disagree or Sometimes
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/AHRQ-Hospital-Survey-2.0-Users-Guide-5.26.2021.pdf
January 01, 2021 - ” to “Always”) and also include a “Does not apply or Don’t know”
response option. … If you usually administer paper surveys, it might be
better to continue with that data collection method … Agree or Most of the time 4
Neither agree nor disagree or Sometimes 3
Disagree or Rarely 2
Strongly … disagree or Never 1
Does not apply/Don’t know 9
Clean the Data
Paper Surveys. … The midpoints
of the scales are reported as a separate category (Neither Agree nor Disagree or Sometimes
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-case2.html
November 01, 2014 - The executive sponsor is usually the director of the department implementing Lean and is also on the … A facilitator also felt the outcomes never reached the desired level. … Solutions generated in RCI events sometimes required the use of capital resources. … Staff who were close to the work were not always those making the changes. … interviewees, especially from the ED, noted that when staff outside the work area defined solutions, there was usually
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psnet.ahrq.gov/perspective/emergence-trigger-tool-premier-measurement-strategy-patient-safety
May 01, 2012 - One of the reasons may be that we focused on a lot of errors that never impact a patient. … Some never impact a patient and some can dramatically impact a patient. … that occurred in the Medicare study—more than a quarter of the patients had them and minor events were sometimes … So we'll always have a human review to assess and validate its accuracy. … DC : The feedback loop is usually that air traffic controller having access to the patient information
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psnet.ahrq.gov/perspective/conversation-withdavid-c-classen-md-ms
May 01, 2012 - One of the reasons may be that we focused on a lot of errors that never impact a patient. … Some never impact a patient and some can dramatically impact a patient. … that occurred in the Medicare study—more than a quarter of the patients had them and minor events were sometimes … So we'll always have a human review to assess and validate its accuracy. … DC : The feedback loop is usually that air traffic controller having access to the patient information
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www.ahrq.gov/workingforquality/events/webinar-2014-qdr-working-together-to-improve-health-care.html
November 01, 2016 - workforce development, or measurement and feedback, whether it's in quality improvement work, there's always … worse access to care compared with reference group, 2012 [Slide 20]
Ernest Moy: And we, of course, always … Sometimes people find that to be informative and help them understand the importance of these gaps and … We usually have standard reference populations, so, we usually compare everything to the majority population … For primary care providers I know it's a challenge, because probably people are coming in now who never
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psnet.ahrq.gov/perspective/disclosure-medical-error
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 to … The vast majority of patients who are injured by their care never sue. … But that follow-up conversation usually is an opportunity to again explain what happened. … March 1, 2012
Quality and patient safety improvement is never finished.
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursing-home-users-guide-2.0.pdf
March 01, 2025 - ” to “Always”) and include a “Does Not Apply or Don’t Know”
response option. … If you usually administer paper
surveys, it might be better to continue with that data collection method … Agree or Most of the time 4
Neither Agree nor Disagree or Sometimes 3
Disagree or Rarely 2
Strongly … Disagree or Never 1
Does Not Apply or Don’t Know 9
Clean the Data
Paper surveys. … The midpoints
of the scales are reported as a separate category (Neither Agree nor Disagree or Sometimes
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psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulness
February 01, 2014 - know that it is a really bad thing to have an alert window pop up and interrupt you on the computer, sometimes … say "I'm a good multitasker," presuming that they're somehow better than others, but the evidence is usually … quickly notice the extent and toll of interruptions, multitasking, and all manner of things that had never … We will always want to have discussions about those things. They're not going to go away. … Sometimes the evidence supports that, and sometimes it doesn't. How do you navigate those waters?
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www.ahrq.gov/sites/default/files/2024-02/goldstein-report.pdf
January 01, 2024 - NTMx-AKI is
usually nonoliguric in nature,46 so we did not use the KDIGO urine output criteria. … Patient safety never
sacrificed to get work done
1-5 4.12 2.29
Item A18. … It is also possible to identify variables that are “almost always
necessary.” … study hospitals; that is to say, the absence of strong network participation usually, but not
always … ,
usually, or sometimes necessary, and coverage, which assesses the empiric relevance of the necessary
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psnet.ahrq.gov/perspective/conversation-sharon-k-inouye-md-mph
December 01, 2012 - Then I just never stopped. … It's usually multifactorial. … The answer is always yes, and then I ask, okay, what? And they tell me. … It would create this perverse incentive never to recognize it. … been shown to markedly reduce the duration of delirium when compared with benzodiazepines.( 12,13 ) Sometimes
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psnet.ahrq.gov/node/861738/psn-pdf
January 31, 2024 - While complete tendon disruptions are usually clinically obvious, the anatomic location, physical structure … Flexor tendons lie deep
and are more difficult—and sometimes impossible—to visualize. … Referred patients
should ideally be seen within 5 days, though this is not always possible. … cognitive aids such as algorithms, checklists, and visual aids.16 While a checklist or
visual aid is never
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psnet.ahrq.gov/sites/default/files/2024-01/spotlight_case_laceration_needed_exam_not_x-ray_final.pdf
January 01, 2024 - inadequacies-physical-examination-cause-medical-errors-and-adverse-events-collection
Approach to Improving Patient Safety (2)
• While complete tendon disruptions are usually … are relatively easy to identify
and inspect.
• Flexor tendons lie deep and are more difficult—and sometimes … – Referred patients should ideally be seen within 5 days, though this is not always
possible.
– In … algorithms, checklists, and visual aids.16
31
Human Error (5)
While a checklist or visual aid is never
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/methods-guidance-topic-nomination_methods.pdf
November 01, 2012 - The research
associate is usually a master’s level or higher researcher with an epidemiology, biological … In other cases, further
input from the nominator is necessary, but is not always possible if the nomination … The literature usually suggests the
relevant parameters for a topic, which are compared with the PICO … emerging technologies that are diffusing rapidly, although they may be older
technologies that have never … group but before final disposition of the topic, or
during topic refinement, and EHC Program staff usually
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psnet.ahrq.gov/perspective/conversation-freya-spielberg-md-mph
September 28, 2022 - Sometimes it might just take one training session to get someone up to speed, but the other people who … Or when someone has diabetes that’s out of control with an elevated hemoglobin A1c, or when someone never … In my work in community clinic settings, we always had a behavioral health person integrated into the … 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
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digital.ahrq.gov/sites/default/files/docs/publication/r18hs018649-levick-final-report-2014.pdf
January 01, 2014 - The simple interfaces (ADT data: registration and insurance information usually found in the
billing … different with the exception that it’s generally not anticipated or
expected, but when available it’s usually … However, this often resulted in inefficient
data retrieval processes accompanied by frustration and sometimes … perceived information availability increased over time, our interviews
suggest that providers did not always … birth outcomes, we also find that that the mechanism for increasing information availability
was not always
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www.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-patient-experience-vol1.pdf
July 01, 2023 - Although patient and family conceptions of adverse events do not always conform to clinical
definitions … past findings have relevance for future research in diagnostic safety:
■ Patient Experiences Must Sometimes … I never saw the surgeon again after I left the hospital the first time. … A person going from state to state may have
much information the new doctor never becomes aware of. … that emerge from interactions with a regular source of primary care, since patients
and family can usually
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/migraine-prevention_disposition-comments.pdf
April 18, 2013 - Here are
some comments for the investigators to consider:
One general question is that usually multiple … with inevitable differences across
studies we used mixed (or multiple) treatment
comparisons (MTCs), sometimes … We revised the tables always reporting 95%CI. … Here are
some comments for the investigators to consider:
One general question is that usually multiple … The structure of the evidence-based reports
always includes the executive summary with
the most important
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www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/chcanys-qi-primer.pdf
August 01, 2017 - In the research literature, PF is sometimes called quality
improvement coaching or practice enhancement … support multiple practices and don’t face the same
competing demands as internal facilitators, who sometimes … When thinking about SMAART goals, always begin by referencing the Model for
Improvement and identify … Note: Don’t confuse aim drift, or backing away from a stretch goal (which
usually isn’t a good tactic … alternate text Passed Figures require alternate text
Nested alternate text Passed Alternate text that will never