Results

Total Results: 2,150 records

Showing results for "happened".

121. Premortem Assessment | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mrsa-prevention/surgery/premortem-assessment.html
     April 01, 2025 - Ask your team: What could have happened? What could have gone wrong?

122. Sensemakingnotes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/identify/sensemakingnotes.docx
     August 08, 2012 - Defects identification CUSP asks 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. … · What happened to the patient? Slide 22 DO: Play the video. … ASK: · According to the nurse, what happened?

123. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module6/module6-care-for-caregiver.pptx
     May 01, 2011 - 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 … Develop understanding of what happened. Support individual(s) involved in event. … High-acuity areas have little time to integrate what has happened. Intense fear of the unknown. … Having time to integrate what has happened, especially in high-acuity areas such as emergency departments

124. 091-Decolonization-Implementation-Fg (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/091-decolonization-implementation-fg.docx
     April 01, 2025 - This tool asks four important questions: what happened, why did it happen, how to reduce the likelihood … To determine what happened, the CUSP team reviewed data from the EHR and found that documentation on … Further investigating more about why this happened, the team realized that in the follow up call 2 weeks … In determining what happened, the CUSP team reviewed their audits over the last few months and found

125. Sensemaking and Learn From Defects for Perinatal Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-slides.html
     July 01, 2023 - The discovery event addresses what happened. … Arrows pointing downward lead from one question to the next: Question 1: What happened?

126. Sensemaking and Learn From Defects for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
     www.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.

127. DESC Technique for Conflict With Residents and Families (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/DESC-technique.pdf
     June 01, 2021 - She is not acting like herself today, and the last time this happened, someone told you she had a UTI

128. Morningbriefing (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/morningbriefing.doc
     August 07, 2012 - What happened overnight that I need to know about?

129. Identify Defects Module Alternate Text | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/modules/identify/alt-text.html
     March 01, 2013 - The discovery event addresses what happened. … Tools to Learn From Defects     Slide 21 Learning From Defects: Four Questions What happened … Slide 22 What Happened?

130. Learning From Defects | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mrsa-prevention/surgery/learning-from-defects.html
     April 01, 2025 - There are four key questions in the CUSP Learning From Defects process: What happened?

131. Sensemaking and Learn From Defects for Perinatal Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/perinatal-care/modules/teamwork/learn-from-defects-slides.html
     May 01, 2017 - The discovery event addresses what happened. … Arrows pointing downward lead from one question to the next: Question 1: What happened?

132. New Mexico IMPaCT: Catalyzing Community Health Transformation in Kansas | Agency for Healthcare Research and Quality
     www.ahrq.gov/ncepcr/funding/grants/impact/success-story/ks.html
     March 01, 2017 - “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

133. Improving Patient Safety Culture to Provide Safer Care
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2016-materials/teamstepps-monthly-webinar-august2016.pptx
     January 01, 2016 - TeamSTEPPS® Improving Patient Safety Culture Slide ‹#› CUSP Tool #3: Learning From Defects What happened … and record what happened Study: How do the results compare to your prediction?

134. New Mexico IMPaCT: Catalyzing Community Health Transformation in Kansas | Agency for Healthcare Research and Quality
     www.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

135. Fallpxtool5A (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallpxtoolkit/fallpxtool5a.docx
     January 29, 2013 - witnessed Make a clear distinction between what was seen or heard and the patient’s account of what happened

136. Conducting a Morning Briefing | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/toolkit/morning-briefing.html
     December 01, 2012 - Briefing process What happened overnight that I need to know about?

137. Sensemaking and Learn From Defects for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/perinatal-care/modules/teamwork/learn-from-defects-fac-guide.html
     May 01, 2017 - 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.

138. Learn-From-Defects-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.docx
     May 01, 2017 - 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.

139. Patient and Family Engagement for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/pf-engagement-fac-guide.html
     July 01, 2023 - Providers communicate the facts of what happened and assure the patient and family that they will receive … A hospital committed to transparency offers an apology that the incident happened. … An explanation of what happened. A meaningful discussion of projected outcomes.

140. Learning From Defects | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mrsa-prevention/toolkit/learning-from-defects.html
     October 01, 2024 - There are four key questions in the CUSP Learning From Defects process: What happened?