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Total Results: 3,974 records

Showing results for "happened".

181. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34677/psn-pdf
     February 09, 2011 - Patients wanted disclosure of all harmful errors, why the errors happened, and how recurrences would

182. Talking With Residents and Family Members About Antibiotics (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/family-antibiotics.pdf
     June 01, 2021 - June 2021 Talking With Residents and Family Members About Antibiotics The last time this happened

183. Sensemaking and Learn From Defects for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
     www.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.

184. 089-Or-Traffic-Fg (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/089-or-traffic-fg.docx
     April 01, 2025 - This included looking at what happened and why, how to reduce the likelihood of this happening again, … Slide 13 Case Example: What Happened? SAY: So, what happened?

185. Morningbriefing (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/morningbriefing.doc
     June 02, 2025 - What happened overnight that I need to know about?

186. Sensemaking and Learn From Defects for Perinatal Safety | Agency for Healthcare Research and Quality
     www.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?

187. Learning From Defects | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mrsa-prevention/surgery/learning-from-defects.html
     April 01, 2025 - There are four key questions in the CUSP Learning From Defects process: What happened?

188. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44876/psn-pdf
     February 10, 2016 - This analysis of the incident breaks down what happened and explores how attention to mindfulness and

189. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45455/psn-pdf
     June 29, 2017 - Recommended best practices for error disclosure include being honest about what happened, explicitly

190. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47636/psn-pdf
     December 12, 2018 - The piece includes the perspectives of the patient's family and from the organization regarding what happened

191. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47335/psn-pdf
     August 22, 2018 - whose daughter died from medical error and the resistance she faced when trying to understand what happened

192. Spotlight Case July 2008 (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.239_slideshow.ppt
     May 01, 2011 - suitable quiet room, avoid distractions Listen and empathize – assess patient’s understanding of what happened … , provide support Explain the facts – identify the adverse event early, explain clearly what happened … another institution (under the care of other providers) There is some uncertainty about exactly what happened

193. Identify Defects Module Alternate Text | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/modules/identify/alt-text.html
     March 01, 2013 - The discovery event addresses what happened. … Tools to Learn From Defects     Slide 21 Learning From Defects: Four Questions What happened … Slide 22 What Happened?

194. Talking With Residents and Family Members About Urinary Tract Infections (UTIs) (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/family-members-UTI.pdf
     June 01, 2021 - Last time this happened, the doctor prescribed an antibiotic and he felt better.

195. Talking With Residents and Family Members About Lower Respiratory Tract Infections (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/family-RTI.pdf
     June 01, 2021 - Last time this happened, the doctor prescribed an antibiotic and she got better.

196. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33628/psn-pdf
     February 01, 2006 - way to rationalize or excuse the error to avoid its disclosure), and second, if he does discuss what happened … Would you like me to tell you about what happened?" And let's assume she said yes. … Jones, what happened was your mother was supposed to receive 10 units of insulin, and there was an … instead you're dancing around the periphery saying, "We had this problem, and we're sorry that it happened

197. Resilient Health Care Society. | PSNet
     psnet.ahrq.gov/issue/resilient-health-care-society
     October 09, 2019 - October 9, 2019 The Emperor’s New Clothes: Or Whatever Happened To “Human Error”?

198. Scisafetynotes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/understand/scisafetynotes.docx
     June 02, 2025 - When learning from defects, 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 … SAY: Apply these four Learning From Defects questions to this example. · What happened?

199. 091-Decolonization-Implementation-Fg (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/091-decolonization-implementation-fg.docx
     April 01, 2025 - This tool asks four important questions: what happened, why did it happen, how to reduce the likelihood … To determine what happened, the CUSP team reviewed data from the EHR and found that documentation on … Further investigating more about why this happened, the team realized that in the follow up call 2 weeks … In determining what happened, the CUSP team reviewed their audits over the last few months and found

200. Learn-From-Defects-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.docx
     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.