-
www.ahrq.gov/hai/tools/surgery/modules/sustainability/learn-from-defects-fac-notes.html
December 01, 2017 - First-order problem solving is reactionary, rather than proactive. … As James Reason wrote more than two decades ago, “Rather than being the main instigators of an accident … You need to understand rather than judge. Ask clarifying questions if you’re not sure. … Go a mile deep and an inch wide—that is, spend time and energy investigating one problem deeply rather … than multiple problems superficially.
-
www.ahrq.gov/news/blog/ahrqviews/consumer-experience-measurement.html
September 01, 2023 - Too often we measure patient experience for a single transaction, rather than an episode of care or longitudinally … If patients perceive that they were treated differently than other patients for any number of reasons—such … We are in a profoundly better place in understanding patients’ perceptions than we were just a few years
-
www.ahrq.gov/hai/tools/mvp/modules/cusp/learn-from-defects-fac-guide.html
February 01, 2017 - Second-order problem solving focuses on identifying system issues rather than one-time solutions. … involved in a defect are often put in a position which leads to patient harm because of the system itself, rather … than because of a sole individual’s mistake. … Isolate how the providers were in the position to make a mistake, rather than approaching the defect … This type of education is stronger than emails and one-way lectures.
-
www.ahrq.gov/hai/tools/mvp/modules/sustainability/premortem-scorecard-fac-guide.html
February 01, 2017 - Rather, it’s the adaptive or cultural components of this work that are not only the toughest to implement … Ask:
Is one more likely to derail your effort than another? … Remember that sustainment is more than a project; it is a process. … Tackle any remaining barriers or any barriers as they come up proactively rather than reactively. … Rather than provide an established scorecard template, we recommend a flexible model with room for local
-
www.ahrq.gov/ncepcr/tools/obesity/obpcp3.html
May 01, 2014 - However, the BMI provides you with an objective measure of obesity status rather than a subjective assessment … Open-ended questions are those that require the receiver to respond with more than a yes or no answer … stopping, the other person is then "expected" to uphold their end of the conversation and make a statement rather … than simply answering an open-ended question. … There is no actual patient-clinician demonstration of MI in this video, but rather it describes the principles
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Cunningham_11.pdf
January 29, 2008 - than process-level errors (or
1
behaviors) occurring during health care. … Also, given the aim of proactive measurement
and intervention, they are process- rather than outcome-based … than on the identification of individuals at fault. … Implementing CPOE is more easily accomplished with hospital-employed
caregivers rather than with professionals … than an event to be dreaded and avoided.
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/report/rep5.html
June 01, 2010 - Rather, as described in Section II, TEP members and other stakeholders ranked a series of constructs … patterns, interagency coordination agreements, or treatment protocols, which are assessed at a systems, rather … than individual, level.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/ascwebinar/brownslides.pdf
June 02, 2025 - vs 82% for pilot ASCs
Staff are treated fairly when they
make mistakes.
81%
89%
Learning, rather … than blame, is
emphasized when mistakes are
made.
78%
70%
Staff are told about patient safety
-
www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/communication-facilitator-guide.pdf
November 01, 2019 - Use punctuation in your head when you
communicate information rather than long
statements that go on … It’s
best to focus on the common goal of providing the
safest care to the patient rather than attacking … I think the risk of vancomycin toxicity is greater than the
risk that he has an MRSA infection. … a good idea to speak with the patient’s nurses and
others who have spent more time at the bedside than … In this case, rather that discuss
the pros and cons of ceftazidime/avibactam, it’s
probably best first
-
www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/dxsafety-implementation-tip-sheet.pdf
June 02, 2025 - structure:
� Consider rolling out each module across several meetings with your diagnostic
team, rather … than covering all the material during a single meeting.
� Keep presentations short, sharing no more … than 15 minutes of easy-to-
understand information at a time, and include focused time for group
discussion
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/community-pharmacy/pharmacy-survey-english.docx
June 02, 2025 - This pharmacy places more emphasis on sales than on patient safety
|_|1
|_|2
|_|3
|_|4
|_|5
|_ … This pharmacy helps staff learn from their mistakes rather than punishing them
|_|1
|_|2
|_|3
|_ … Less than 6 months
|_|b. 6 months to less than 1 year
|_|c. 1 year to less than 3 years
|_| … d. 3 years to less than 6 years
|_|e. 6 years to less than 12 years
|_|f. 12 years or more … More than 40 hours per week
3. What is your position in this pharmacy?
-
www.ahrq.gov/ncepcr/care/coordination/atlas/chapter1.html
June 01, 2014 - to broad groups of patients, such as the general population or patients with any chronic condition, rather … than measures tailored to individuals with a single disease or condition. … development, improvement initiatives, and discussion around care coordination may have heightened, rather … than clarified, this ambiguity. … Rather, in this section we discuss several challenges highlighted by the experience of developing and
-
www.ahrq.gov/prevention/resources/chronic-care/clinical-community-relationships-measures-atlas/ccrm-atlas-ex522.html
March 01, 2013 - N/A
Numerator:
N/A
Development & testing:
The interview to measure surgery-level (rather … than individual clinician-level) clinical linkages was developed, piloted, reviewed, and evaluated with
-
www.ahrq.gov/prevention/resources/chronic-care/clinical-community-relationships-measures-atlas/ccrm-atlas-ex521.html
March 01, 2013 - N/A
Numerator:
N/A
Development & testing:
The interview to measure surgery-level (rather … than individual clinician-level) clinical linkages was developed, piloted, reviewed, and evaluated with
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Valade_46.pdf
May 05, 2008 - Prevent or correct system
defects in ways that respond to patient and staff needs rather than
training … than blaming. … Chapters were identified using capital
letters (rather than numbers) to indicate that recommended objectives … Rather
than become overwhelmed by the large volume of public testimony with which it started, the
Commission … than blame when the unexpected
happens, and set aside competition when it comes to keeping patients
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/025-ss-why-choose-cusp-fg.docx
April 01, 2025 - Rather than policies handed down from above, CUSP empowers frontline staff to own and address the problems … CUSP believes that defects are learning opportunities, rather than punishable actions. … hospital compared to 350 hospitals in surrounding states
· A 40 percent reduction in CLABSI across more than
-
www.ahrq.gov/hai/tools/mvp/modules/cusp/daily-goals-rounds-slides.html
February 01, 2017 - length of stay (LOS) 4
Image: Line graph illustrating how the ICU length of stay reduces by more than … Are provider- rather than patient-centered. … Use divergent discussion (brainstorming) rather than convergent discussion (explicit plan).
-
www.ahrq.gov/ncepcr/reports/2024-annual-report/profile-p14-barton.html
May 01, 2024 - Colorado, patients who were Hispanic and those living in rural areas were more likely to use phone rather … than video telehealth visits. 1 Additional results from patient surveys showed that those who had video … telehealth visits had higher trust in the service provided than those who had phone visits.
-
www.ahrq.gov/sites/default/files/2024-11/becker-bix-report.pdf
January 01, 2024 - In addition,
participants searched for any changes rather than prespecified target objects, allowing … Second, rather than use our mock brand names and relatively generic packing, we
used the branded products … Experiment 4, that the FOP warning
label might increase the participants’ bias to say inappropriate rather … than mock versions of those medications. … front-of-pack warning label seems to result from
a shift in the bias to say that a product is safe rather
-
www.ahrq.gov/hai/cauti-tools/archived-webinars/navigating-hierarchy-transcript.html
December 01, 2017 - We have maintained a culture of subordination to a superior rather than teacher to learner or partner … than the exercise of power. … We're allowing certain behaviors to progress because they come from a person in authority rather than … We spent so much time coaching negative behavior rather than finding that, what I call the positive deviant … than disincentivizing or blaming the rest.