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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-patient-experience-fry-webinar.pdf
January 01, 2014 - patient
reports
Whether something
that should happen
actually did happen,
and how often it
happened
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/situ/simulation_facguide.docx
May 01, 2017 - 16
SAY:
The debrief process usually involves four steps: introducing the process, describing what happened … Slide 17
SAY:
The next step in the debrief process is to describe what happened. … In discussing why things happened in the scenario as they did, the team should focus on critical aspects … They can explain how and why certain outcomes may have happened “Was the decision made right (correctly
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-facilitator-guide.docx
June 01, 2021 - A simple way to put this approach into action is by asking four questions:
· What happened? … Slide 12
What Happened?
SAY:
Let’s first consider what happened to our resident.
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-fac-guide.html
July 01, 2023 - Defects identification
CUSP asks L&D unit staff to work through a defect and ask—
What happened? … The recovery side is completed when the event is a near miss, that is, something that happened to stop … What happened?
Step 1. Reconstruct the timeline to understand what happened.
Step 2.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/hotline/healthcare-safety-hotline-appendixc.pdf
July 01, 2015 - What happened? … Where do you believe it happened?
2.1c. When did it happen?
2.1d. … Why do you think this happened?
2.2 What is the name of the patient? … What happened? … Where do you believe it happened?
2.1c. When did it happen?
2.1d.
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes6.html
August 01, 2022 - I started to doubt myself… I thought maybe if I'd have done something another way, it wouldn't have happened … anonymous second-victim: "Every single day for months, I'd walk in and think, 'Everyone knows what happened … inquisition by identifying key individuals involved in the event, developing an understanding of what happened … Having time to integrate what has happened, especially in high-acuity areas such as emergency departments
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps/diagnosis-improvement/dx-journey-mr-kane.pptx
June 14, 2016 - We are still trying to make sense of everything that happened…
4
Slide
Background – Joe Kane
49-year-old … This had happened a few times before as well and usually he would go to see Dr. … that he had missed a few dialysis appointments, which resulted in the excess fluid, and that this had happened … that he had missed a few dialysis appointments, which resulted in the excess fluid, and that this had happened
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/patfamilyengagement/CUSP_Patient_Family_Engagement_Facilitator_Notes.docx
September 13, 2013 - critical, feedback, and focus on how to prevent a problem from reoccurring rather than focusing on what happened … Providers communicate the facts of what happened and assure the patient and family that they will receive … communicated to the patient and family:
· An apology for any unreasonable care
· An explanation of what happened … A hospital committed to transparency offers an apology that the incident happened.
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ce.effectivehealthcare.ahrq.gov/sops/international/medical-office/translators.html
January 01, 2010 - ( Note: This question asks about things that happened in the past—should use past tense, not present … accurate, complete, and timely information with: ( Note: This question also asks about things that happened
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cusp-icu-slides.pptx
April 01, 2022 - Defects13
1
2
3
4
AHRQ Safety Program for ICUs: Preventing CLABSI and CAUTI
Applying CUSP ׀ 13
What happened … AHRQ Safety Program for ICUs: Preventing CLABSI and CAUTI
Applying CUSP ׀ 14
Understand Why Defect Happened
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/medical-office/resources/infotransMOSOPS.pdf
January 01, 2010 - (NOTE: This question asks about things that happened in
the past – should use past tense, not present … accurate,
complete, and timely information with:
(NOTE: This question also asks about things that happened
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps/diagnosis-improvement/dx-journey-presenter-notes.pdf
March 01, 2022 - We are still trying to
make sense of everything that happened…
Slide 5
Background – Joe Kane … This had happened a few
times before as well and usually he would go to see Dr. … he had
missed a few dialysis appointments,
which resulted in the excess fluid, and
that this had happened … that he had missed a few dialysis
appointments, which resulted in the excess fluid, and that this had happened
-
ce.effectivehealthcare.ahrq.gov/ncepcr/research-transform-primary-care/transform/impactgrants/impact-ks-success-story.html
April 01, 2015 - “We were motivated by collaborations that had happened between the University of New Mexico and New Mexico … cooperative extension folks at Kansas State to develop collaborations, which is not something that had happened
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/recognizing-success-transcript.docx
May 01, 2017 - use the checklist and ask about it, we decided to put up a bulletin board in the break room, which happened
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ce.effectivehealthcare.ahrq.gov/hai/cusp/videos/index.html
September 01, 2019 - Identifying and Ranking Defects What Happened? Why Did It Happen?
-
ce.effectivehealthcare.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/exh3.html
August 01, 2022 - In your own words, please describe what happened. ___________________________ (Collect open-ended narrative
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/publications/files/sustainability-guideapa.pdf
January 01, 2009 - Topic
AHRQ Safety Program for Reducing CAUTI in Hospitals
A Model for Sustaining and Spreading Safety Interventions
Appendix A. Action Plan Tool for Project Sustainability
The Purpose of This Tool
This tool is intended to support sustainability efforts for your catheter-associated urinary tract infect…
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/situ/simulation_facguide.pdf
May 01, 2017 - SAY:
The debrief process usually involves four
steps: introducing the process, describing
what happened … Program
of In Situ Simulations 11
SAY:
The next step in the debrief process is to
describe what happened … In discussing why things happened in the
scenario as they did, the team should focus on
critical aspects … They can explain how and why
certain outcomes may have happened
“Was the decision made right (correctly
-
ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-3.html
June 01, 2023 - their safety concerns did so through a sequence of open-ended questions 18 :
Please tell us what happened … Considering only respondents for whom the diagnostic problem happened 3 or more years in the past, 28 … clinicians, scaffolding questions asked about these encounters and encouraged respondents to “explain what happened … , how it happened, and how it felt to you.”
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/resources/tools/implement/facility-action-plan.docx
January 01, 2018 - BLADDER SCAN – POLICY #2202 12/11/06
AHRQ Safety Program for Long-Term Care: HAIs/CAUTI
AHRQ Safety Program for Reducing CAUTI in Hospitals
Facility Action Plan Template
The purpose of this tool is to support quality improvement efforts by identifying opportunities for improvement, strategies, and steps to accomplis…