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Showing results for "happened".

101. Minnesota lets nurses practice while disciplinary investigations drag on. Patients keep getting hurt. | PSNet
     psnet.ahrq.gov/issue/minnesota-lets-nurses-practice-while-disciplinary-investigations-drag-patients-keep-getting
     April 22, 2020 - August 23, 2023 Inside the preventable deaths that happened within a prominent transplant … View More Related Resources Inside the preventable deaths that happened

102. CAHPS Elicitation Protocol Webcast (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-webinar-jan-2017-schlesinger.pdf
     January 01, 2017 - 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.

103. How CAHPS Surveys Measure Patient Experience | Agency for Healthcare Research and Quality
     www.ahrq.gov/cahps/news-and-events/podcasts/measure-patient-experience-podcast.html
     March 01, 2017 - Measuring patient satisfaction tells you how patients feel about their care, but not what actually happened … care setting—something such as clear communication with a provider—actually did happen or how often it happened … Because CAHPS survey questions focus on whether or not something specific happened in a health care setting

104. Learning-From-Antibiotic-Adverse (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/learning-from-antibiotic-adverse.docx
     June 01, 2021 - (What happened?) Step 2. … (What happened?) 2.

105. In Conversation with…Thomas H. Gallagher, MD | PSNet
     psnet.ahrq.gov/perspective/conversation-withthomas-h-gallagher-md
     January 01, 2009 - You just went and told the patient what happened. … They protect the words, "I'm sorry," but they don't protect the statement about what happened. … Here's what we know about what happened, and what we've done to mitigate its impact on you. … I think an expression of regret about what happened at that point is also appropriate. … But that follow-up conversation usually is an opportunity to again explain what happened.

106. Disclosure of Medical Error | PSNet
     psnet.ahrq.gov/perspective/disclosure-medical-error
     January 01, 2009 - You just went and told the patient what happened. … They protect the words, "I'm sorry," but they don't protect the statement about what happened. … Here's what we know about what happened, and what we've done to mitigate its impact on you. … I think an expression of regret about what happened at that point is also appropriate. … But that follow-up conversation usually is an opportunity to again explain what happened.

107. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/090-decolonization-implementation.pptx
     April 01, 2025 - Surgical Services Decolonization Implementation 10 Case Example: Learning From Defects Tool What happened … MRSA Prevention | Surgical Services Decolonization Implementation 12 Cardiac Case Example—1 What Happened … Prevention | Surgical Services Decolonization Implementation 15 Neuro-Spine Surgery Case Example—1 What Happened … Prevention | Surgical Services Decolonization Implementation 18 Orthopedic Surgery Case Example—1 What Happened

108. In Conversation with Jessica Behrhorst about The Evolution of Root Cause Analysis | PSNet
     psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evolution-root-cause-analysis
     February 26, 2025 - They happened behind closed doors, and we did not talk about them much. … They saw that a group of people got together to discuss what happened, but then frontline staff would … not know what happened after that. … There are three basic questions we use all the time: “What happened?” “Why did it happen?” … In RCA 2 , we use the Five Whys to ask why this event happened and create causal chains.

109. The Evolution of Root Cause Analysis | PSNet
     psnet.ahrq.gov/perspective/evolution-root-cause-analysis
     February 26, 2025 - They happened behind closed doors, and we did not talk about them much. … They saw that a group of people got together to discuss what happened, but then frontline staff would … not know what happened after that. … There are three basic questions we use all the time: “What happened?” “Why did it happen?” … In RCA 2 , we use the Five Whys to ask why this event happened and create causal chains.

110. Unstoppable: this doctor has been investigated at every level of government. How is he still practicing? | PSNet
     psnet.ahrq.gov/issue/unstoppable-doctor-has-been-investigated-every-level-government-how-he-still-practicing
     September 16, 2020 - December 20, 2023 Inside the preventable deaths that happened within a prominent transplant … September 20, 2023 Inside the preventable deaths that happened within a prominent transplant

111. Learning From Defects
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/024-ss-cusp-learning-from-defects.pptx
     April 01, 2025 - Four Questions The following four questions help teams address and prevent defects systemwide: What happened … Safety Program for MRSA Prevention | Surgical Services Learning From Defects 7 Question One What Happened … for MRSA Prevention | Surgical Services Learning From Defects Learning From Defects Process: What Happened … The following four questions help teams analyze and prevent defects: What happened?

112. AHRQ Safety Program for MRSA Prevention
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/002-cusp-learning-defects.pptx
     October 01, 2024 - Questions The following four questions help teams address and prevent defects system-wide: What happened … AHRQ Safety Program for MRSA Prevention | ICU & Non-ICU Learning From Defects 7 Question 1 What Happened … AHRQ Safety Program for MRSA Prevention | ICU & Non-ICU Learning From Defects LFD Process: What Happened … The following four questions help teams analyze and prevent defects: What happened?

113. Removing Insult from Injury—Disclosing Adverse Events | PSNet
     psnet.ahrq.gov/perspective/removing-insult-injury-disclosing-adverse-events
     February 01, 2006 - Here are two possible answers—look around to see if anyone else saw what happened, then rub the scrape … most common reason patients sue is they felt it was the only way they could get information about what happened … .( 5 ) The patient who later learns about what happened and suspects a "cover-up" is likely to become … We recommend a simple, four-step approach: (i) tell the patient what happened, using plain language; … Would you like me to tell you about what happened?" And let's assume she said yes.

114. Exploring clinical lessons learned by experienced hospitalists from diagnostic errors and successes. | PSNet
     psnet.ahrq.gov/issue/exploring-clinical-lessons-learned-experienced-hospitalists-diagnostic-errors-and-successes
     January 15, 2025 - Citation Related Resources From the Same Author(s) “I had no idea this happened … May 18, 2022 View More Related Resources “I had no idea this happened

115. Approach to Residents With Reported Penicillin Allergy (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/penicillin-allergy.pdf
     June 01, 2021 - _________________ o What year was it or how old was the resident when the reaction happened? … taking when he or she had the reaction: What year was it or how old was the resident when the reaction happened

116. Public Reporting of Patients' Comments with Quality Measures: How Can We Make It Work? (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/20140603_QI/3_rachel_grob.pdf
     June 02, 2025 - (past 12 months) Positive experiences: 1 Question with narrative guide (what happened, how did it … (past 12 months) Positive experiences: 1 Question with narrative guide (what happened, how did it happen

117. Establishing a Program of In Situ Simulations: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/situ/simulation-fac-guide.html
     July 01, 2023 - Slide 18: Debriefing: Describe What Happened Say: The next step in the debrief process is to describe … what happened. … Slide 19: Debriefing: Describe What Happened Say: It is important for the facilitator to empathize … 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

118. Engage the Team and Applying CUSP in the ICU Setting Slides (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cusp-icu-notes.docx
     April 01, 2022 - It requires ground truth of what actually happened and not presumptions about what might have happened … Remember to ask these four basic questions when considering a defect: · What happened? … guide through the initial investigation for a defects analysis where the primary goal is to learn what happened … If your team created a process map, fishbone chart, or a drawing to illustrate what happened, use it … to map out what happened and include the "why" under each defect.

119. In Conversation with…Albert Wu, MD, MPH | PSNet
     psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph-0
     March 24, 2025 - provider involved in the incident who feels in some way responsible and is emotionally traumatized by what happened … to provide clinical input at a time when the physician or nurse really needs help interpreting what happened … I think understanding what happened and what could have been done, or the lessons that might be learned … evaluating them, but who can provide an objective sophisticated assist to help them think through what happened … Rick Kidwell, our former hospital counsel, used to advise us to tell the patient what happened, be honest

120. Understand the Science of Safety for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
     www.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?