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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/implementation-guide/appendix-j.pdf
April 13, 2017 - I am curious, what do you think happened?
How did that make you feel? … I wonder what you think happened? … I am curious, what do you think happened?
How did that make you feel? … I am curious, what do you think happened?
How did that make you feel? … I am curious, what do you think happened?
How did that make you feel?
Coaching Tool
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preventiveservices.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/implementation-guide/app-j.html
May 01, 2017 - I am curious, what do you think happened?
How did that make you feel? … I wonder what you think happened? … I am curious, what do you think happened?
How did that make you feel? … I am curious, what do you think happened?
How did that make you feel? … I am curious, what do you think happened?
How did that make you feel?
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preventiveservices.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/notes.html
August 01, 2022 - Slide 11
Say:
The Disclosure Checklist includes:
What happened–identify the adverse … event early in the disclosure, explain what happened in a way that is easy to understand, explain what … is known about why the adverse event occurred, but DO NOT guess or assume anything about what happened … Tell the patient what should have happened. … This question is often a stand-in for "How could this have happened?"
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preventiveservices.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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preventiveservices.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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preventiveservices.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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preventiveservices.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?
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preventiveservices.ahrq.gov/hai/cusp/modules/identify/identify.html
December 01, 2012 - What Happened? Slide 23. Why Did It Happen? Slide 24. … From Defects
Return to Contents
Slide 21: Learning From Defects: Four Questions
What happened … Return to Contents
Slide 22: What Happened?
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/tpc/impact-ks-success-story.pdf
April 01, 2015 - “We were motivated by collaborations that had happened between the University of New Mexico and
New … cooperative extension folks at Kansas State to develop collaborations, which is
not something that had happened
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preventiveservices.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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preventiveservices.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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preventiveservices.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
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preventiveservices.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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preventiveservices.ahrq.gov/hai/cusp/videos/index.html
September 01, 2019 - Identifying and Ranking Defects What Happened? Why Did It Happen?
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preventiveservices.ahrq.gov/hai/cusp/modules/understand/science-safety-notes.html
July 01, 2018 - When learning from defects, 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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preventiveservices.ahrq.gov/hai/cusp/modules/identify/index.html
July 01, 2018 - Video Segments
What Happened? (43 sec.)
Why Did It Happen? (34 sec.)
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preventiveservices.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes4.html
August 01, 2022 - To strengthen system accountability, we want to learn what happened, why it happened, what normally happens
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preventiveservices.ahrq.gov/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/customer-service/strategy6q-custservice-standards.html
March 01, 2020 - "It's the doctor's fault and I can't believe that happened."
"I'm sorry that happened.
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/20140603_QI/reporting-patients-comments-transcript.pdf
June 01, 2014 - Please explain what happened, how it happened, and how it felt to you.” … Please explain what happened, how it happened, and how it felt to you.” … or how much detail is conveyed, or the completeness of the story, how much do you kind of
know what happened … experiences that you wish had gone
differently over the past 12 months, and to explain to us what happened … , how it happened, and how it felt to
you.
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/shadowing.doc
August 08, 2012 - What happened during the shadowing exercise that involved multiple practice domains?