-
www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/invitation-messages-transcript.pdf
September 01, 2019 - People said that there's nothing wrong with these messages that it's
okay to have them in letters, but … We do not have information about any of the characteristics
of the respondents such as what's wrong
-
www.ahrq.gov/research/findings/making-healthcare-safer/mhs3/exe-summary.html
March 01, 2020 - Errors: Patient Identification Errors in the Operating Room
Compliance audit
Incidence of wrong-site … operating room and theaters
Drawing meaningful statistical comparisons is difficult because wrong-site
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/report/apv.html
June 01, 2010 - Forum
Residential care
Patient death or serious disability associated with medication error (wrong
-
www.ahrq.gov/hai/cauti-tools/archived-webinars/engaging-nurse-physician-patient-transcript.html
December 01, 2017 - Again, the most important component of this process is that if focuses on what went wrong not who did … something wrong.
-
www.ahrq.gov/hai/cauti-tools/archived-webinars/cauti-sustainability-transcript.html
December 01, 2017 - you use, I will challenge you that anytime you have a CAUTI, you drill down and figure out what went wrong … If you don't fix it, you don't know what went wrong and then you don't fix it, you likely will continue
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/cauti-sustainability-transcript.docx
January 01, 2014 - you use, I will challenge you that anytime you have a CAUTI, you drill down and figure out what went wrong … If you don't fix it, you don't know what went wrong and then you don't fix it, you likely will continue
-
www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/about/ncepcr-older-adults-presentation.pptx
March 15, 2025 - health problem(s) or communicate that explanation to the patient”
- Delayed diagnosis
- Missed or wrong
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/impguide.html
December 01, 2014 - What is likely to go wrong? What approach would you take to address these issues?
-
www.ahrq.gov/sites/default/files/publications/files/interimhacrate2014_2.pdf
November 19, 2015 - Saving Lives and Saving Money: Hospital-Acquired Conditions Update - Interim Data From National Efforts To Make Care Safer, 2010-2014
Saving Lives and Saving Money: Hospital-Acquired Conditions
Update
Interim Data From National Efforts To Make Care Safer, 2010-2014
Summary
Interim estimates for 2014 show a s…
-
www.ahrq.gov/sites/default/files/publications2/files/interimhacrate2014_cx.pdf
November 19, 2015 - Saving Lives and Saving Money: Hospital-Acquired Conditions Update - Interim Data From National Efforts To Make Care Safer, 2010-2014
Saving Lives and Saving Money: Hospital-Acquired Conditions
Update
Interim Data From National Efforts To Make Care Safer, 2010-2014
Summary
Interim estimates for 2014 show a sust…
-
www.ahrq.gov/patient-safety/settings/hospital/red/toolkit/redtool6.html
March 01, 2025 - Root Cause Analysis Root cause analysis is the study of when things go wrong to identify ways bad outcomes
-
www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-23-documenting-work-with-practices.pdf
September 01, 2015 - At the same time, sharing too much information or the wrong type of
information can derail the process
-
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. … Doing the survey to do a survey is the
wrong reason to do it.
-
www.ahrq.gov/hai/cauti-tools/archived-webinars/patient-family-centered-care-transcript.html
December 01, 2017 - talk about in the CAUTI interventions, and creating independent checks and learning when things go wrong … Creating independent checks and learning when things go wrong are areas where patients and families bring
-
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 - talk about in the CAUTI interventions, and creating independent checks and learning when things go wrong … Creating independent checks and learning when things go wrong are areas where patients and families bring
-
www.ahrq.gov/hai/tools/surgery/modules/sustainability/learn-from-defects-fac-notes.html
December 01, 2017 - Don’t just focus on what went wrong; also focus on what went right.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy1/Strat1_Tool_5_InfoSession_508.pptx
April 02, 2025 - instead of critical – thinking about how to make things better as opposed to focusing only on what is wrong
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/healthitpatientsafetyitemset-hospitals-pilottestreport.pdf
March 01, 2018 - Information was entered into the wrong
patient health record
68%
28%
2% 1% 0% 0%
0%
20%
40%
60%
-
www.ahrq.gov/hai/tools/surgery/modules/implementation/ssi-bundle-fac-notes.html
October 01, 2020 - system that makes it easier for providers to do the right thing and harder for providers to do the wrong
-
www.ahrq.gov/hai/cusp/toolkit/content-calls/briefing.html
April 01, 2013 - going so the people don't think that you're writing down everything that you believe they're doing wrong … down quickly so not only did we have medications given without anything being signed off, we had the wrong