-
www.ahrq.gov/hai/tools/surgery/modules/implementation/ssi-bundle-slides.html
October 01, 2020 - First example of an instrument defect: Wrong tray; got a medium, but needed major 1 & 2.
-
www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-7-slides.pdf
November 18, 2021 - 28
Problem
The wrong patients are getting
-
www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-9-slides.pdf
February 24, 2022 - ’t work What could be improved
Questions for Tara and Kathy
23
• Chat question: What went wrong
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_learn_from_defects.pptx
December 01, 2017 - decisions
Consider using visualization tools to break down complex defects and discover where steps went wrong … Don’t just focus on what went wrong; also focus on what went right.
-
www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-about-cusp-fac-guide.html
July 01, 2023 - , and this continuum is described in three categories:
Human error—Inadvertently completing the wrong
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Quan_52.pdf
March 10, 2008 - Adaptation of AHRQ Patient Safety Indicators for Use in ICD-10 Administrative Data by an International Consortium
Adaptation of AHRQ Patient Safety Indicators
for Use in ICD-10 Administrative Data
by an International Consortium
Hude Quan, MD, PhD; Saskia Drösler, MD; Vijaya Sundararajan, MD, MPH, FACP;
Euge…
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_data_into_action_facnotes.docx
December 01, 2017 - An investigation helps explain what went right and what went wrong for this particular patient.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/coaching/coaching-slideset.pptx
May 01, 2017 - Ambulatory Surgery
23
Example of making the team guess what you are thinking
“Can you tell me what you did wrong
-
www.ahrq.gov/hai/cauti-tools/archived-webinars/no-more-cauti-preventing-cauti-transcript.html
November 01, 2015 - technique is noted, making it all about patient safety, not necessarily about who's right and who's wrong
-
www.ahrq.gov/hai/cauti-tools/archived-webinars/no-more-cauti-transcript.html
December 01, 2017 - technique is noted, making it all about patient safety, not necessarily about who's right and who's wrong
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/No_More_CAUTI_Preventing_CAUTI_transcript.docx
May 05, 2015 - technique is noted, making it all about patient safety, not necessarily about who's right and who's wrong
-
www.ahrq.gov/hai/tools/mvp/modules/cusp/assess-psc-hsop-fac-guide.html
February 01, 2017 - In a way, this culture helps us understand what is good, bad, right, and wrong, so that we can also understand
-
www.ahrq.gov/hai/tools/surgery/modules/on-boarding/science-of-safety-fac-notes.html
December 01, 2017 - condition, a patient fall, a venous thromboembolism, a medication error, a surgical site infection, wrong-site
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/learn/learn-facilitator-guide.docx
May 01, 2017 - risk, and this continuum is described in three categories:
Human error—Inadvertently completing the wrong
-
www.ahrq.gov/patient-safety/reports/hotline/conclusios6.html
May 01, 2016 - appetite among health care organizations for collecting information from consumers about things that go wrong
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_7-implementation-speaker-notes.pdf
July 01, 2023 - Things
have gone completely wrong on a number of fronts. What could have caused
this?" … • Identify risk points where things could or do go wrong.
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_7-implementation-speaker-notes.pdf
July 01, 2023 - Things
have gone completely wrong on a number of fronts. What could have caused
this?" … • Identify risk points where things could or do go wrong.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Shah_99.pdf
March 23, 2008 - medical error was defined as “the failure to
complete a planned action as intended or the use of a wrong … no workup
Standard of care: Performing a workup
“Continue to do a procedure knowing
something is wrong … workup
Standard of care: Performing a workup
“Continue to do a
procedure knowing
something is wrong
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/2020_MOSOPS_Part_I-rev0921.pdf
January 01, 2020 - The wrong chart/medical record
was used for a patient.
98% Positive
67%
Not in the
past 12
months … Medical information was
filed, scanned, or entered into
the wrong patient's chart/
medical record … The wrong chart/medical record was used for a patient. … Medical information was filed, scanned, or entered into the
wrong patient’s chart/medical record.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Connelly.pdf
January 01, 2003 - believe most clinical errors are preventable. 3.13 .525 Agree
12. are willing to discuss what went wrong … clinical mishap.
11. believe most clinical errors are preventable.
12. are willing to discuss what went wrong