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www.innovations.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/item-sets/elicitation/cahps-patient-narrative-elicitation-protocol-qa-03-01-2017.pdf
January 01, 2017 - Please explain what happened,
how it happened, and how it felt to you.
PN-4. … Please explain what happened,
how it happened, and how it felt to you.
PN-5.
-
www.innovations.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/understand-sci-fac-guide.html
July 01, 2023 - When learning from defects, L&D unit 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?
Why did it happen?
How will you reduce the risk of recurrence?
-
www.innovations.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/implementing-new-protocol-transcript.pdf
October 01, 2018 - Because before understanding what has actually happened to a patient we need to know what it is that … We probe, please explain what happened, how it happened and how it felt to you in order to get that complete … And again please
explain what happened, how it happened and how it felt to you. … Is this something that happened once or is this
something that happens to you often? … And how did what happened get brought about?
-
www.innovations.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/job-aid-last10-patients-audit.pdf
May 18, 2021 - ago, care may not reflect current processes, and clinicians and staff may not be able
to recall what happened
-
www.innovations.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
-
www.innovations.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.
-
www.innovations.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apd.html
August 01, 2022 - What happened during the handoff? … Was there anything that happened during the handoff that may have contributed to the event?
-
www.innovations.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
-
www.innovations.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.
-
www.innovations.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
-
www.innovations.ahrq.gov/hai/cusp/videos/index.html
September 01, 2019 - Identifying and Ranking Defects What Happened? Why Did It Happen?
-
www.innovations.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/pf-engagement-facilitator-guide.pdf
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
-
www.innovations.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.
-
www.innovations.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?
-
www.innovations.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes4.html
August 01, 2022 - To strengthen system accountability, we want to learn what happened, why it happened, what normally happens
-
www.innovations.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/visual/visual-mgmt-pdsa-form.docx
May 01, 2017 - Module 2: Example
AHRQ Safety Program for Ambulatory Surgery
Management Practices for Sustainability
Module 5: Visual Management
Sample “Plan-Do-Study-Act”[footnoteRef:1] Form [1: “Plan-Do-Study-Act” refers to a method for testing changes in clinical practice. In the “plan” step, lay out the specifications of your…
-
www.innovations.ahrq.gov/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/customer-service/strategy6q-custservice-standards.html
March 01, 2020 - "It's the doctor's fault and I can't believe that happened."
"I'm sorry that happened.
-
www.innovations.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.doc
November 15, 2019 - Survey on Patient Safety (facility version)
Survey on Patient Safety
Instructions
This survey asks for your opinions about patient safety issues, medical error, and event reporting in your facility and will take about 10 to 15 minutes to complete.
If you do not wish to answer a question, or if a question does not app…
-
www.innovations.ahrq.gov/news/blog/ahrqviews/diagnostic-safety-conversation.html
October 01, 2021 - People tend to remember things that happened recently.
-
www.innovations.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.doc
June 09, 2016 - Hospital Survey on Patient Safety
SOPSTM Hospital Survey
Version: 1.0
Language: English
Note
· For more information on getting started, selecting a sample, determining data collection methods, establishing data collection procedures, conducting a Web-based survey, and preparing and analyzing data, and producing re…