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  1. 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.
  2. 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.
  3. 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.
  4. 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
  5. 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
  6. 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?
  7. 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.
  8. 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.
  9. 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.
  10. 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.
  11. 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.
  12. 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.
  13. 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.
  14. 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
  15. 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.
  16. 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.
  17. 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
  18. 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
  19. 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?
  20. 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.

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