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psnet.ahrq.gov/node/43739/psn-pdf
December 03, 2014 - The father's quest to understand what happened
led to a comprehensive inquiry that revealed regulatory
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/learning_pt_narratives_053123-ginsberg.pdf
June 02, 2025 - established by other
organizations
7
CAHPS Surveys
• CAHPS surveys measure experience:
► What happened
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psnet.ahrq.gov/node/44108/psn-pdf
November 06, 2015 - highlights how insufficient transparency can prevent
patients and their families from learning about what happened
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psnet.ahrq.gov/node/866730/psn-pdf
September 18, 2024 - Following adverse events, many patients and families welcome disclosure from their providers about what
happened
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/contentcalls/briefing-slides/Morning-Briefing-and-Shadowing-July-12-2011-508.ppt
January 01, 2011 - that day
Night charge nurse
Day charge nurse
Morning Briefing Process
Three simple questions
What happened … What Happened Overnight That
I Need to Know About?
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psnet.ahrq.gov/issue/err-human-what-happens-when-surgeons-err
August 04, 2021 - Study
To err is human, but what happens when surgeons err?
Citation Text:
Lin JS, Olutoye OO, Samora JB. To err is human, but what happens when surgeons err? J Pediatr Surg. 2023;58(3):496-502. doi:10.1016/j.jpedsurg.2022.06.019.
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psnet.ahrq.gov/issue/what-happens-when-doctors-make-diagnostic-errors
December 18, 2019 - Audiovisual Presentation
What Happens When Doctors Make Diagnostic Errors?
Citation Text:
What Happens When Doctors Make Diagnostic Errors? The Peoples Pharmacy. Show 1186: National Public Radio. October 24, 2019.
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Save to your library
Prin…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/129-ss-blank-lfd.docx
April 01, 2025 - Provide a clear, thorough, and objective explanation of what happened.
II. … What Happened?
Reconstruct the timeline and explain what happened.
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psnet.ahrq.gov/node/842779/psn-pdf
January 12, 2011 - respond to disruptions, monitor their
environment, anticipate future impacts, and learn from what happened
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psnet.ahrq.gov/node/851200/psn-pdf
July 05, 2023 - Claims that the facility purposely sought to hide information
that the suicide happened were unsubstantiated
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psnet.ahrq.gov/node/854262/psn-pdf
October 04, 2023 - towards-conceptualizing-patients-partners-health-systems-systematic-review-and-descriptive
https://psnet.ahrq.gov/issue/what-happened-patient-safety
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www.ahrq.gov/hai/tools/mrsa-prevention/surgery/premortem-assessment.html
April 01, 2025 - Ask your team: What could have happened? What could have gone wrong?
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psnet.ahrq.gov/issue/what-happens-when-things-go-wrong
April 24, 2018 - Commentary
What happens when things go wrong?
Citation Text:
Brandom BW, Callahan P, Micalizzi DA. What happens when things go wrong? Paediatr Anaesth. 2011;21(7):730-6. doi:10.1111/j.1460-9592.2010.03513.x.
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psnet.ahrq.gov/issue/what-happens-when-healthcare-innovations-collide
December 06, 2017 - Commentary
What happens when healthcare innovations collide?
Citation Text:
Pendharkar SR, Woiceshyn J, da Silveira GJC, et al. What happens when healthcare innovations collide? BMJ Qual Saf. 2016;25(1):9-13. doi:10.1136/bmjqs-2015-004441.
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www.ahrq.gov/sites/default/files/wysiwyg/nhguide/6_TK1_T6-Managing_Resident_and_Family_Expectations_Final.docx
October 01, 2016 - Has that ever happened to you?
What happened?
How did you handle it?
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www.ahrq.gov/sites/default/files/wysiwyg/nhguide/6_TK1_T6-Managing_Resident_and_Family_Expectations_Final.pdf
October 01, 2016 - • Has that ever happened to you?
• What happened?
• How did you handle it?
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/identify/sensemaking.pptx
January 01, 2006 - What happened?
2. Why did it happen?
3. What will you do to reduce the risk of recurrence?
4. … What Happened?
22
Why Did It Happen?
23
What Will You Do To Reduce the Risk of Recurrence?
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psnet.ahrq.gov/node/49450/psn-pdf
June 01, 2004 - jargon-free statement that an error
occurred and a basic description of what the error was and why it happened … want their physician to apologize, which demonstrates that the physician
genuinely cares about what happened … Patients especially value understanding how
an error happened and how recurrences will be prevented, … error's cause and prevention may
stimulate the physician to think more critically about why the error happened … Determining exactly how an error happened
and formulating a plan for preventing recurrences can be especially
-
psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure
May 01, 2011 - jargon-free statement that an error occurred and a basic description of what the error was and why it happened … want their physician to apologize, which demonstrates that the physician genuinely cares about what happened … Patients especially value understanding how an error happened and how recurrences will be prevented, … error's cause and prevention may stimulate the physician to think more critically about why the error happened … Determining exactly how an error happened and formulating a plan for preventing recurrences can be especially
-
psnet.ahrq.gov/node/47159/psn-pdf
August 01, 2018 - frequently referred to as Safety-I, involved responding to adverse
events and near misses after they happened