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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/125-cusp-science-safety.pptx
April 01, 2025 - ”
- James Reason, Human Error13
The CUSP approach is to understand the system behind the defect, not … Prevention | Surgical Services
The Science of Safety
16
Swiss Cheese Model13
| 17
Adapted from: Reason … Reason J. Human error: models and management. BMJ. 2000 Mar 18;320(7237):768-70. PMID: 10720363.
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www.ahrq.gov/hai/tools/mvp/modules/technical/daily-care-processes-slides.html
January 01, 2017 - Enter the number associated with the reason for contraindication:
Enter 1 if the contraindication … What is the reason elevating the HOB to ≥30 degrees, when compared to a horizontal surface, is contraindicated … Enter the number associated with the reason for contraindication:
0. Other.
1. Hypotension.
2.
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www.ahrq.gov/talkingquality/explain/communicate/framework.html
December 01, 2022 - Also in "Communicating Key Information Upfront"
Give People a Reason To Look at the Report
Provide
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/dailycare-processes-slides.pptx
January 01, 2017 - mechanical ventilation AND with C entered in the previous column
Enter the number associated with the reason … for patients receiving mechanical ventilation AND with C entered in the previous column
What is the reason … Enter the number associated with the reason for contraindication:
0.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/4es-early-mobility-slides.pptx
January 01, 2017 - , but NOT on infusion of benzodiazepine, narcotic, or propofol
Medically inappropriate (orthopedic reason … e.g., fracture of long bone, spine, or pelvis)
Medically inappropriate (circulatory or respiratory reason … femoral sheath) as delineated in the medical screening algorithm
Medically inappropriate (for any other reason
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www.ahrq.gov/hai/tools/surgery/modules/sustainability/premortem-fac-notes.html
December 01, 2017 - Consider the concerns that you identified for each reason.
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www.ahrq.gov/cahps/surveys-guidance/item-sets/search.html
March 03, 2025 - Health literacy
C-HL04
Provider talked with patient about reason
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www.ahrq.gov/teamstepps-program/curriculum/implement/activity/change.html
June 01, 2023 - acquire a sense of urgency only when a tragic and publicized patient harm occurs, which may be one reason … listening to the resister helps identify an important improvement that benefits all staff and overcomes the reason … The value of short-term wins that can be celebrated is one reason you should consider simple, less complex
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www.ahrq.gov/sites/default/files/wysiwyg/health-literacy/3rd-edition-toolkit/primary-care-health-literacy-assessment.pdf
March 01, 2024 - Our practice shares important
referral information (e.g., reason
for referral, pertinent medical
history … Make sure the patient understands the reason for the referral.
Offer help with the referral. … for Talk About Costs: Tool #23
Screening and Implementation Tools
Tools for Linking to Resources
Reason … for Referral_________________________________
Community Referral Form: City Medical Care
Reason for
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www.ahrq.gov/cahps/surveys-guidance/item-sets/search.html?page=0
January 03, 2024 - Health literacy
C-HL4
Provider talked with patient about reason
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/notes.html
August 01, 2022 - What is the reason or motivation for the CANDOR process being implemented now? … Leaders can use personal stories to help staff understand the background and reason for change. … enduring if the change leaders at all levels of the organization have a clear understanding of the reason
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www.ahrq.gov/hai/tools/surgery/modules/sustainability/learn-from-defects-slides.html
December 01, 2017 - ”
— James Reason, Human Error, 1990 1
Slide 8: AHRQ Safety Program for Surgery—Sustainability … Slide 25: References
Reason J. Human Error: models and management. BMJ 2000;320:768-70.
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www.ahrq.gov/chain/practice-tools/practice-guidelines/recent-research-findings.html
March 01, 2017 - The most common reason for provider nonadherence to recommendations was that there was not enough staff
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_premortem_facnotes.docx
December 01, 2017 - Consider the concerns that you identified for each reason.
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www.ahrq.gov/cahps/surveys-guidance/item-sets/search.html?order=field_supplemental_topics&page=12&search_api_fulltext=&sort=asc
Browse Supplemental Items for CAHPS Surveys
Users of standardized CAHPS surveys may incorporate supplemental items in order to meet the needs of their organizations, local markets, and/or audiences. Use the filters at left to identify the supplemental items available for the CAHPS survey of interest. Select an item…
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www.ahrq.gov/sops/events/webinars/just-culture/introduction.html
January 01, 2017 - which people are clear about where the line is drawn between acceptable and unacceptable behavior " (Reason
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www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/hospital/hospwebinar/just-culture-intro.html
January 01, 2017 - which people are clear about where the line is drawn between acceptable and unacceptable behavior " (Reason
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www.ahrq.gov/sites/default/files/publications/files/ahcptemplen.pdf
February 14, 2013 - Date/time of appt
Provider name
Provider site information
Reason for appt
Provider phone
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www.ahrq.gov/sites/default/files/publications/files/ahcptemplsp.pdf
February 14, 2013 - (in Spanish)
Provider name
Provider site information
Reason for appt
Provider phone
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/red/toolkit/ahcptemplen.pdf
February 14, 2013 - Date/time of appt
Provider name
Provider site information
Reason for appt
Provider phone