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Showing results for "happened".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73498/psn-pdf
    July 14, 2021 - //psnet.ahrq.gov/issue/drug-error-eskenazi-hospital-killed-prominent-cancer-researcher-heres-how-it-happened

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/860386/psn-pdf
    January 10, 2024 - Descriptions include knowing what has happened; learning from the factual; learning from experience;

  3. CUSP Videos | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/cusp/videos/index.html
    September 01, 2019 - Identifying and Ranking Defects What Happened? Why Did It Happen?

  4. Exhibit 3. Reporting of patient safety events | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/exh3.html
    August 01, 2022 - In your own words, please describe what happened. ___________________________ (Collect open-ended narrative

  5. Log | Digital Healthcare Research

    digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/log
    January 01, 2023 - recording information such as time, location, and personnel, and then a main column for recording what happened

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866254/psn-pdf
    July 10, 2024 - consequences-whistle-blowing-integrative-review https://psnet.ahrq.gov/issue/inside-preventable-deaths-happened-within-prominent-transplant-center

  7. Understand the Science of Safety for Perinatal Safety (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-facilitator-guide.pdf
    May 01, 2017 - 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 … • What happened? • Why did it happen? • How will you reduce the risk of recurrence?

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853247/psn-pdf
    September 06, 2023 - bearing-burden-black-mothers-america https://psnet.ahrq.gov/issue/doctors-must-stop-tuning-out-black-women-it-happened-me-pregnant-ob-gyn

  9. The Power of Patient Stories for Improving the Patient Experience webcast - Ginsberg (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/patient-narratives-webinar-ahrq.pdf
    June 02, 2025 - tools and products. 7 CAHPS surveys of patient experience of care Standardized surveys: What happened

  10. Sensemakingnotes (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/identify/sensemakingnotes.docx
    June 02, 2025 - Defects identification CUSP asks 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. … · What happened to the patient? Slide 22 DO: Play the video. … ASK: · According to the nurse, what happened?

  11. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/overview-cuspmvp-facguide.docx
    January 01, 2017 - So, what happened? It is not enough to simply understand what happened. … understand from the point of view of the people who were involved in the event—both staff and patients—what happened … By identifying how the defect happened, we get to the point where we can understand what system factors … contributed to defect occurrence and why it happened.

  12. Overview of the Comprehensive Unit-based Safety Program for Application to Mechanically Ventilated Patients: Facilitator Guide | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/tools/mvp/modules/cusp/overview-cusp-mvp-facguide.html
    February 01, 2017 - So, what happened?  It is not enough to simply understand what happened. … understand from the point of view of the people who were involved in the event—both staff and patients—what happened … By identifying how the defect happened, we get to the point where we can understand what system factors … contributed to defect occurrence and why it happened.

  13. 114-Mrsa-Prevention-Learning-From-Defects (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/114-mrsa-prevention-learning-from-defects.docx
    October 01, 2024 - Provide a clear, thorough, and objective explanation of what happened. II. … What happened? In the space below, identify the MRSA infection or other event.

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33651/psn-pdf
    June 01, 2007 - We publish an annual report that shows the number of events that happened in each facility, the types … Once it happened and once the first report came out, I think everyone realized that it wasn't going … there's a concern that the local paper is going to focus on you or target you because of something that happened … been less positive or targeted facilities a bit more, but even so, those worst-case scenarios haven't happened … I get calls sometimes from patients or family members when something really sad has happened to them

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44917/psn-pdf
    November 30, 2016 - gather insights from staff, patients, and family members regarding what caused the failure and why it happened

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37024/psn-pdf
    January 02, 2017 - describe the implementation of a nonpunitive reporting system at their hospital and the improvements that happened

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/864863/psn-pdf
    March 20, 2024 - girl-who-cried-pain-bias-against-women-treatment-pain https://psnet.ahrq.gov/issue/doctors-must-stop-tuning-out-black-women-it-happened-me-pregnant-ob-gyn

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865595/psn-pdf
    January 01, 2024 - psnet.ahrq.gov/primer/maternal-safety https://psnet.ahrq.gov/issue/doctors-must-stop-tuning-out-black-women-it-happened-me-pregnant-ob-gyn

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851870/psn-pdf
    July 31, 2023 - Based on that event, we were able to alert healthcare workers about what happened to bring attention … You need a feedback loop built into the system to share what happened and what the organization is doing … Being able to take what happened and share those stories across different settings is helpful. … We receive 300,000 reports a year but do not often get information on why something happened or how it … happened.

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48129/psn-pdf
    August 14, 2019 - the author argues that the clinician and organization still have the responsibility to document what happened
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