-
www.ahrq.gov/hai/cusp/videos/05g-what-happened/index.html
June 01, 2018 - What Happened? … CUSP Helps Find Out What Happened [43 sec.]
-
www.ahrq.gov/takeheart/assessing/slide-presentation/index.html
August 01, 2023 - What We Planned, What Happened, and What We Learned
TAKEheart: AHRQ's Initiative to Increase … This PowerPoint Presentation explores what the AHRQ TAKEheart team planned from this project, what happened … AHRQ's Initiative To Increase Patient Participation in Cardiac Rehabilitation
What We Planned, What Happened
-
www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-patient-narrative-martino.pdf
June 01, 2021 - 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. … Please explain what happened, how it happened,
and how it felt to you. … If so, 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.
-
www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/defects.html
May 01, 2017 - What happened? (brief description)
2. Why did it happen? … negative factors
What happened to cause the defect?
3. … Has it happened again?
With whom will we share our learning?
-
www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/learn.html
April 01, 2017 - What happened? (brief description)
2. Why did it happen? … negative factors
What happened to cause the defect?
3. … Has it happened again?
With whom will we share our learning?
-
www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-patient-narrative-schlesinger.pdf
December 14, 2021 - Please explain what happened, how it
happened, and how it felt.
Q3. What could be better? … Please explain what happened, how it happened, and how it felt.
Q4. What was surprising? … Please explain what happened, how it happened, and
how it felt.
Q3: What went poorly? … Please explain what happened, how it happened,
and how it felt.
-
www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module2/defects.html
March 01, 2017 - What happened? (brief description)
2. Why did it happen? … negative factors
What happened to cause the defect?
3. … Has it happened again?
With whom will we share our learning?
-
www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/item-sets/CG/supplemental-elicitation-protocol-cgcahps-adult_2357-7a.docx
December 01, 2016 - Please explain what happened, how it happened, and how it felt to you.
C-PN4. … Please explain what happened, how it happened, and how it felt to you.
C-PN5.
-
www.ahrq.gov/cahps/surveys-guidance/item-sets/ch/suppl-narrative-items-child-hospital-survey.html
November 01, 2023 - ’s hospital stay can be an intense experience; please take as much time as you need to tell us what happened … Please explain what happened, how it happened, and how it felt. … Please explain what happened, how it happened, and how it felt.
After H-PN1
H-PN3.
-
www.ahrq.gov/cahps/surveys-guidance/item-sets/cg/suppl-narrative-items-cg-survey40-adult.html
July 01, 2021 - Please explain what happened, how it happened, and how it felt to you. … If so, please explain what happened, how it happened, and how it felt to you.
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/clabsi-learning-from-defects_revised.docx
April 01, 2022 - This worksheet will help your team learn what happened, identify the factors that may have contributed … Record Number: ____________
Date of Birth: _______________
What Happened … In a brief description, document what happened from at least two different staff members. … control and nursing staff are recommended, but others on the team who can give clear descriptions of what happened … Summarize what happened to cause the defect by answering the following questions.
-
www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/item-sets/CG/supplemental-elicitation-protocol-cgcahps-child_2358-7a.docx
December 01, 2016 - Please explain what happened, how it happened, and how it felt to you.
C-PN4. … Please explain what happened, how it happened, and how it felt to you.
C-PN5.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/defects.docx
May 01, 2017 - What happened? (brief description)
2. Why did it happen? … negative factors
What happened to cause the defect?
3. What did we do to manage it?
4. … Has it happened again?
With whom will we share our learning?
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module2/defects.docx
March 01, 2017 - What happened? (brief description)
2. Why did it happen? … negative factors
What happened to cause the defect?
3. What did we do to manage it?
4. … Has it happened again?
With whom will we share our learning?
-
www.ahrq.gov/hai/tools/surgery/modules/sustainability/learn-from-defects-slides.html
December 01, 2017 - Slide 10: What Happened?
Walk the process. … Reconstruct the timeline and reenact what happened. … Slide 11: What Happened?
Image: Questions to ask to learn what happened. … Questions are in color boxes with arrows pointing to a large circle in the center that reads, "What Happened … What happened that had a good outcome?
What happened that had a bad outcome?
-
www.ahrq.gov/cahps/surveys-guidance/item-sets/cg/suppl-narrative-items-cg-survey30-adult.html
August 01, 2021 - Please explain what happened, how it happened, and how it felt to you. … If so, please explain what happened, how it happened, and how it felt to you.
-
www.ahrq.gov/patient-safety/settings/hospital/candor/modules/checklist5.html
August 01, 2022 - patient/family that the organization will conduct an Event Investigation and Analysis to understand what happened … LISTEN AND EMPATHIZE THROUGHOUT
Assess the patient's/family's understanding of what happened … EXPLAIN THE FACTS
What happened?
… Explain what happened in a way that is easy to understand.
… IF THE EVENT WAS PREVENTABLE (DUE TO ERROR)
Tell the patient/family what should have happened
-
www.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?
-
www.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
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/clabsi-learning-from-defects.pdf
April 01, 2022 - This worksheet will help your team learn what happened, identify
the factors that may have contributed … _______________________ Medical Record Number: ____________
Date of Birth: _______________
What Happened … In a brief description, document what happened from at least two different staff
members. … and nursing staff are recommended, but others on the team who can give
clear descriptions of what happened … Summarize what happened to cause the defect by
answering the following questions.