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Total Results: 1,482 records

Showing results for "happened".

121. Sensemaking and Learn from Defects for Perinatal Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.pdf
     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.

122. Establishing a Program of In Situ Simulations: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/situ/simulation-slides.html
     July 01, 2023 - Slide 18: Debriefing: Describe What Happened First, each participant states their name, role, and … Slide 19: Debriefing: Describe What Happened It is important for the participants to realize it … Measure 1 Processes (Measures of Performance): Explain how and why certain outcomes may have happened

123. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/088-or-traffic.pptx
     April 01, 2025 - Prevention | Surgical Services OR Traffic 12 Case Example: Using the Learning From Defects Tool What happened … Services AHRQ Safety Program for MRSA Prevention | Surgical Services OR Traffic Case Example: What Happened

124. New Mexico IMPaCT: Catalyzing Community Health Transformation in Kansas (pdf file)
     www.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

125. What is Patient Experience and How Does CAHPS Measure It? (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/primer-patient-experience.pdf
     June 02, 2025 - Patient experience refers to what happened in a health care setting.

126. Job Aid: “Last 10 Patients” Chart Audit (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/job-aid-last10-patients-audit.pdf
     June 02, 2025 - ago, care may not reflect current processes, and clinicians and staff may not be able to recall what happened

127. Pf-Engagement-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/pf-engagement-facilitator-guide.docx
     May 01, 2017 - 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. … communicated to the patient and family: An apology for any unreasonable care An explanation of what happened

128. Transcript: How To Have Difficult Conversations With Colleagues Around Infection Prevention Practices (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/difficult-conversations-transcript.pdf
     April 01, 2022 - needs to be experts on this because they're the ones that can see where the conversations should have happened … Maybe there's improvement in how it happened, but the essence of the conversation was important.

129. Cusp Patient Family Engagement Facilitator Notes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/patfamilyengagement/CUSP_Patient_Family_Engagement_Facilitator_Notes.docx
     June 02, 2025 - critical, feedback, and focus on how to prevent a problem from reoccurring rather than focusing on what happened … Providers communicate the facts of what happened and assure the patient and family that they will receive … communicated to the patient and family: · An apology for any unreasonable care · An explanation of what happened … A hospital committed to transparency offers an apology that the incident happened.

130. Appendix C: The Health Care Safety Hotline: Operations Manual (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/hotline/healthcare-safety-hotline-appendixc.pdf
     July 01, 2015 - What happened? … Where do you believe it happened? 2.1c. When did it happen? 2.1d. … Why do you think this happened? 2.2 What is the name of the patient? … What happened? … Where do you believe it happened? 2.1c. When did it happen? 2.1d.

131. Simulation Facguide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/situ/simulation_facguide.docx
     May 01, 2017 - 16 SAY: The debrief process usually involves four steps: introducing the process, describing what happened … Slide 17 SAY: The next step in the debrief process is to describe what happened. … 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

132. CAHPS End of Life Care Survey (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/end-of-life/end-of-life-care-survey-english.pdf
     December 03, 2024 - Please explain what happened, where it happened, and how it felt to you and/or your family member.

133. Session 1 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mod2sess1.html
     October 01, 2014 - staff—benefits from an environment that supports discussion and learning from unwanted events that happened … or nearly happened.

134. Changing-System-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-facilitator-guide.docx
     June 01, 2021 - A simple way to put this approach into action is by asking four questions: · What happened? … Slide 12 What Happened? SAY: Let’s first consider what happened to our resident.

135. Specific Barriers and Challenges to Reporting and Learning From Diagnostic Errors | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-psychological-safety-3.html
     September 01, 2023 - The conclusion that an error happened at all might depend on the reviewer’s perspective; in fact, consensus

136. TeamSTEPPS® Diagnosis Improvement: Diagnostic Journey of Mr. Kane (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/dx-journey-presenter-notes.pdf
     June 02, 2025 - 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

137. Journey of Mr. Kane
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/dx-journey-mr-kane.pptx
     June 02, 2025 - We are still trying to make sense of everything that happened… 4 Slide Background – Joe Kane 49-year-old … This had happened a few times before as well and usually he would go to see Dr. … that 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

138. Understanding CAHPS® Surveys: A Primer for New Users (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-patient-experience-fry-webinar.pdf
     January 01, 2014 - patient reports  Whether something that should happen actually did happen, and how often it happened

139. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/esrd/using-checklists/checklistandauditslides.pptx
     September 03, 2014 - When learning from defects, 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? Step 1. Reconstruct the timeline to understand what happened. Step 2. … What happened? 2. Why did it happen? 3. What will you do to reduce the risk of recurrence? 4.

140. Engage the Team and Applying CUSP in the ICU Setting Facilitator Guide
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cusp-icu-slides.pptx
     April 01, 2022 - Defects13 1 2 3 4 AHRQ Safety Program for ICUs: Preventing CLABSI and CAUTI Applying CUSP ׀ 13 What happened … AHRQ Safety Program for ICUs: Preventing CLABSI and CAUTI Applying CUSP ׀ 14 Understand Why Defect Happened