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Showing results for "happened".

41. The Evolution of Root Cause Analysis | PSNet
    psnet.ahrq.gov/perspective/evolution-root-cause-analysis
    February 26, 2025 - They happened behind closed doors, and we did not talk about them much. … They saw that a group of people got together to discuss what happened, but then frontline staff would … not know what happened after that. … There are three basic questions we use all the time: “What happened?” “Why did it happen?” … In RCA 2 , we use the Five Whys to ask why this event happened and create causal chains.

42. In Conversation with Jessica Behrhorst about The Evolution of Root Cause Analysis | PSNet
    psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evolution-root-cause-analysis
    February 26, 2025 - They happened behind closed doors, and we did not talk about them much. … They saw that a group of people got together to discuss what happened, but then frontline staff would … not know what happened after that. … There are three basic questions we use all the time: “What happened?” “Why did it happen?” … In RCA 2 , we use the Five Whys to ask why this event happened and create causal chains.

43. Exploring clinical lessons learned by experienced hospitalists from diagnostic errors and successes. | PSNet
    psnet.ahrq.gov/issue/exploring-clinical-lessons-learned-experienced-hospitalists-diagnostic-errors-and-successes
    January 15, 2025 - Citation Related Resources From the Same Author(s) “I had no idea this happened … May 18, 2022 View More Related Resources “I had no idea this happened

44. Removing Insult from Injury—Disclosing Adverse Events | PSNet
    psnet.ahrq.gov/perspective/removing-insult-injury-disclosing-adverse-events
    February 01, 2006 - Here are two possible answers—look around to see if anyone else saw what happened, then rub the scrape … most common reason patients sue is they felt it was the only way they could get information about what happened … .( 5 ) The patient who later learns about what happened and suspects a "cover-up" is likely to become … We recommend a simple, four-step approach: (i) tell the patient what happened, using plain language; … Would you like me to tell you about what happened?" And let's assume she said yes.

45. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/33627/psn-pdf
    February 01, 2006 - Here are two possible answers—look around to see if anyone else saw what happened, then rub the scrape … common reason patients sue is they felt it was the only way they could get information about what happened … .(5) The patient who later learns about what happened and suspects a "cover-up" is likely to become … We recommend a simple, four-step approach: (i) tell the patient what happened, using plain language;

46. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/863766/psn-pdf
    March 06, 2024 - psnet.ahrq.gov/issue/racism-and-health https://psnet.ahrq.gov/issue/doctors-must-stop-tuning-out-black-women-it-happened-me-pregnant-ob-gyn

47. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/33674/psn-pdf
    February 01, 2009 - That was appropriate when the adverse events just happened and they cost institutions more money to … So if the hospital is going to be tagged with an adverse event that happened at another place, that's … advance directives and other elements of complex care that take time, where the metric of whether it happened … Under the old payment system, when the adverse event happened, the hospital would get paid an extra … And I think that's happened.

48. In Conversation with…Albert Wu, MD, MPH | PSNet
    psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph-0
    March 24, 2025 - provider involved in the incident who feels in some way responsible and is emotionally traumatized by what happened … to provide clinical input at a time when the physician or nurse really needs help interpreting what happened … I think understanding what happened and what could have been done, or the lessons that might be learned … evaluating them, but who can provide an objective sophisticated assist to help them think through what happened … Rick Kidwell, our former hospital counsel, used to advise us to tell the patient what happened, be honest

49. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/860386/psn-pdf
    January 10, 2024 - Descriptions include knowing what has happened; learning from the factual; learning from experience;

50. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/73498/psn-pdf
    July 14, 2021 - //psnet.ahrq.gov/issue/drug-error-eskenazi-hospital-killed-prominent-cancer-researcher-heres-how-it-happened

51. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/866254/psn-pdf
    July 10, 2024 - consequences-whistle-blowing-integrative-review https://psnet.ahrq.gov/issue/inside-preventable-deaths-happened-within-prominent-transplant-center

52. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/853247/psn-pdf
    September 06, 2023 - bearing-burden-black-mothers-america https://psnet.ahrq.gov/issue/doctors-must-stop-tuning-out-black-women-it-happened-me-pregnant-ob-gyn

53. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/33716/psn-pdf
    September 01, 2011 - you wouldn't want to do the whole aviation style, let's get the black box and find out exactly what happened … Because otherwise, you'll never really find out what happened and any resulting root cause analysis … We know that it's very difficult to track down what's happened if weeks to months have gone by. … and if you can identify them 6 months later, they're probably not going to remember a lot of what happened … They just want to let somebody know that something important happened, and if somebody in a position

54. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/44917/psn-pdf
    November 30, 2016 - gather insights from staff, patients, and family members regarding what caused the failure and why it happened

55. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/37024/psn-pdf
    January 02, 2017 - describe the implementation of a nonpunitive reporting system at their hospital and the improvements that happened

56. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/864863/psn-pdf
    March 20, 2024 - girl-who-cried-pain-bias-against-women-treatment-pain https://psnet.ahrq.gov/issue/doctors-must-stop-tuning-out-black-women-it-happened-me-pregnant-ob-gyn

57. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/49624/psn-pdf
    May 01, 2011 - with a patient or family when the error occurred elsewhere, and when there is uncertainty about what happened … , in which both the referring and accepting physicians talked together with the parents about what happened … Listen and empathize throughout • Assess the patient's understanding of what happened • Identify the … Explain the facts What happened? … • Identify the adverse event early in the disclosure • Explain what happened in a way that is easy to

58. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/33710/psn-pdf
    May 01, 2011 - involved in the incident who feels in some way responsible and is emotionally traumatized by what happened … to provide clinical input at a time when the physician or nurse really needs help interpreting what happened … I think understanding what happened and what could have been done, or the lessons that might be learned … something of this nature, and several of them said that the person helped them to understand what happened … Rick Kidwell, our former hospital counsel, used to advise us to tell the patient what happened, be honest

59. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/865595/psn-pdf
    January 01, 2024 - psnet.ahrq.gov/primer/maternal-safety https://psnet.ahrq.gov/issue/doctors-must-stop-tuning-out-black-women-it-happened-me-pregnant-ob-gyn

60. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/43739/psn-pdf
    December 03, 2014 - The father's quest to understand what happened led to a comprehensive inquiry that revealed regulatory