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ce.effectivehealthcare.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/chapter1.html
August 01, 2022 - What happened?
Was the problem reported? To whom? … What happened when the problem was reported?
What caused the patient safety event to happen?
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/mod5-comm-assessment.pdf
April 01, 2016 - ■ Information is glossed over; minimal information is provided about what happened. … We will be looking into
all of our documentation from this care to determine exactly what happened so … We need to carefully
look at each step to see what happened exactly, so I do not want to give you false … I
will make sure that as we find out what happened you are both made aware. … We also don’t know right now if she has
suffered any injury from what happened, but we will check her
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-facilitator-guide.docx
May 01, 2017 - When learning from defects, L&D unit teams identify—
What happened?
Why did it happen? … Analyzing what happened and why it happened helps the team understand the contributing factors and processes … What happened?
Why did it happen?
How will you reduce the risk of recurrence?
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ce.effectivehealthcare.ahrq.gov/hai/cusp/modules/identify/notes.html
December 01, 2012 - What Happened? Slide 23. Why Did It Happen? Slide 24. … What happened?
Step 1. Reconstruct the timeline to understand what happened.
Step 2. … Return to Contents
Slide 22: What Happened?
Do:
Play the video. … What happened to the patient?
[ D ] Select for Text Description . … Ask:
According to the nurse, what happened?
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/item-sets/elicitation/about-patient-narratives-elicitation-protocol-cg30-2315.pdf
April 24, 2018 - Please explain what happened, how it happened, and how
it felt to you.
PN-4. … Please explain what happened, how it happened, and how
it felt to you.
PN-5. … Please explain what
happened, how it happened, and how it felt to you.
PN-4. … Please explain what
happened, how it happened, and how it felt to you.
PN-5. … Please explain what
happened, how it happened, and how it felt to you.
PN-4.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/patient-narratives-webinar-ahrq.pdf
May 23, 2022 - tools and
products.
7
CAHPS surveys of patient experience of
care
Standardized surveys: What happened
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ce.effectivehealthcare.ahrq.gov/hai/cusp/videos/05h-why-did-happen/index.html
June 01, 2018 - Skip to main content
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/learndefects.doc
August 08, 2012 - Provide a clear, thorough, and objective explanation of what happened.
II. … What happened? Reconstruct the timeline and explain what happened.
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ce.effectivehealthcare.ahrq.gov/cahps/about-cahps/patient-experience/index.html
September 01, 2023 - something that should happen in a healthcare setting (such as clear communication with a provider) actually happened … or how often it happened.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/learning_pt_narratives_053123-ginsberg.pdf
July 03, 2023 - established by other
organizations
7
CAHPS Surveys
• CAHPS surveys measure experience:
► What happened
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-facilitator-guide.pdf
May 01, 2017 - When learning from defects, L&D unit teams
identify—
• What happened?
• Why did it happen? … Analyzing what happened and why it
happened helps the team understand the
contributing factors and … • What happened?
• Why did it happen?
• How will you reduce the risk of
recurrence?
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/item-sets/elicitation/cahps-patient-narrative-elicitation-protocol-qa-03-01-2017.pdf
January 01, 2017 - Please explain what happened,
how it happened, and how it felt to you.
PN-4. … Please explain what happened,
how it happened, and how it felt to you.
PN-5.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/nhguide/6_TK1_T6-Managing_Resident_and_Family_Expectations_Final.docx
October 01, 2016 - Has that ever happened to you?
What happened?
How did you handle it?
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/nhguide/6_TK1_T6-Managing_Resident_and_Family_Expectations_Final.pdf
October 01, 2016 - • Has that ever happened to you?
• What happened?
• How did you handle it?
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/overview-cuspmvp-facguide.docx
January 01, 2017 - So, what happened? It is not enough to simply understand what happened. … understand from the point of view of the people who were involved in the event—both staff and patients—what happened … By identifying how the defect happened, we get to the point where we can understand what system factors … contributed to defect occurrence and why it happened.
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/situ/simulation-fac-guide.html
July 01, 2023 - Slide 18: Debriefing: Describe What Happened
Say:
The next step in the debrief process is to describe … what happened. … Slide 19: Debriefing: Describe What Happened
Say:
It is important for the facilitator to empathize … 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/family-antibiotics.pdf
June 01, 2021 - June 2021
Talking With Residents and Family Members
About Antibiotics
The last time this happened
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ce.effectivehealthcare.ahrq.gov/ncepcr/data-resources/index.html
January 01, 2024 - CAHPS surveys measure what actually happened, or how often something happened to the patient in a healthcare
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ce.effectivehealthcare.ahrq.gov/hai/cusp/toolkit/content-calls/briefing-slides/slides.html
October 01, 2014 - What Happened Overnight That I Need to Know? Slide 9. Where Should Rounds Begin? Slide 10. … Morning Briefing Process
Three simple questions
What happened overnight that I need to know … What Happened Overnight That I Need to Know About?
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/identify/sensemaking.pptx
January 01, 2006 - What happened?
2. Why did it happen?
3. What will you do to reduce the risk of recurrence?
4. … What Happened?
22
Why Did It Happen?
23
What Will You Do To Reduce the Risk of Recurrence?