-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/clabsi-learning-from-defects-revised.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.
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cauti-learning-from-defects.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 … The following questions will ask more details about what happened with the patient with documented CAUTI … Summarize what happened to cause the defect by answering the following questions.
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cauti-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 … The following questions will ask more details about what happened with the patient with documented CAUTI … Summarize what happened to cause the defect by answering the following questions.
-
www.ahrq.gov/takeheart/assessing/index.html
August 01, 2023 - Our PowerPoint Presentation explores what we planned from this project, what happened, and what we learned … Executive Summary
Hybrid Workgroup Evaluation
Presentation on TAKEheart: What We Planned, What Happened
-
www.ahrq.gov/sites/default/files/wysiwyg/takeheart/assessing/takeheart-summary-presentation.pptx
April 26, 2023 - AHRQ’s Initiative to Increase Patient Participation in Cardiac Rehabilitation
What We Planned, What Happened … evaluation/dissemination lead.
1
Overview
Part 1: Background
Part 2: Project Design
Part 3: What Happened … Part 4: Key Takeaways
Part 5: What’s Next
2
What happened includes:
What did and did not go as planned … go to there for project materials since we provided those to them directly by email
13
13
What Happened … :
Trainings/Support
15
Two months into the trainings, COVID happened.
15
COVID Forced a Pause
-
www.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-slides.html
December 01, 2017 - Slide 12: What Happened?
Select a defect to explore. … Slide 13: What Happened?
Image: Questions to ask to learn what happened. … What happened that had a good outcome?
What happened that had a bad outcome? … Slide 14: What Happened?
Reconstruct the timeline and explain what happened. … What happened next?
-
www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/nyp-webinar-grob-narrative-elicitation-protocol.pdf
October 29, 2018 - Please explain what happened, how it happened, and how it felt to you.
4. … Please explain what happened, how it happened, and how it
felt to you.
5.
-
www.ahrq.gov/cahps/surveys-guidance/item-sets/cg/suppl-narrative-items-cg-survey30-child.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/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/mod5-disclosure-checklist.pdf
April 01, 2016 - 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?
■ Identify the adverse event early in the disclosure. … ■ 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/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/nyp-webinar-servati-demo-project.pdf
October 29, 2018 - Standard PG Survey
ADDITIONAL COMMENTS ABOUT THIS VISIT
Now that we have asked you to tell us about what happened … 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/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/tools/applying-cusp/learn_from_defects.docx
December 01, 2017 - What happened? Provide a clear, thorough, and objective explanation of what happened.
II. … What happened?
Reconstruct the timeline and explain what happened. … What happened? Provide a clear, thorough, and objective explanation of what happened.
II. … What happened?
Reconstruct the timeline and explain what happened. … What happened? Provide a clear, thorough, and objective explanation of what happened.
II.
-
www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/patient-narratives-webinar-quality.pdf
May 23, 2022 - Please explain what happened, how it
happened, and how it felt to you.
4. … Please explain what happened, how it
happened, and how it felt to you.
5.
-
www.ahrq.gov/hai/tools/mvp/modules/cusp/learn-from-defects-slides.html
February 01, 2017 - Image: Semi-circle shows the four questions that comprise the learning from defects process:
What happened … Slide 12: What Happened?
Select a defect to learn from. … Slide 13: What Happened?
Image: Chart depicting questions to ask to determine What Happened? … Slide 14: What Happened?
Reconstruct the timeline and explain what happened. … Refer back to any drawings your team used to illustrate what happened.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/learn-from-defects-slides.pptx
January 01, 2017 - staff
Learn From Defects ‹#›
AHRQ Safety Program for Mechanically Ventilated Patients
11
What Happened … Learn From Defects ‹#›
AHRQ Safety Program for Mechanically Ventilated Patients
13
What Happened … What happened that had a good outcome? … Reconstruct the timeline and explain what happened
Consider recreating to make defect real
Visualization … ” of a defect—including the values, attitudes, and beliefs—in order to create a lasting change
What Happened
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cauti-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 … The following questions will ask more details about what happened with the patient
with documented … Summarize what happened to cause the defect
by answering the following questions.
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cauti-learning-from-defects-revised.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 … The following questions will ask more details about what happened with the patient
with documented … Summarize what happened to cause the defect
by answering the following questions.
-
www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/fry-administering.pdf
January 27, 2023 - Patient experience refers to what happened in a health care setting. … Patient Satisfaction
Experience
• Whether something
happened, or how often it
happened
• Frequency
-
www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/ap2.html
August 01, 2022 - Most of the content in conventional messages consists of a description of what happened and what the … Information is glossed over; minimal information is provided about what happened. … We will be looking into all of our documentation from this care to determine exactly what happened so … I will make sure that as we find out what happened you are both made aware. … We also don't know right now if she has suffered any injury from what happened, but we will check her
-
www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/coaching-slides.html
May 01, 2017 - Displays genuine curiosity and interest in what happened. … Can you help me understand what happened?" … Can you help me understand what happened?" … I am curious, what do you think happened?" … What happened during the case?
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects.pptx
December 01, 2017 - What happened that prevented the defect?
What happened that resulted in the defect? … What happened that had a bad outcome?
What Happened? … Explain what happened. Make it visual. … Have participants explain what happened and why it happened. … Review what happened, why it happened, and what interventions were put in place.