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Showing results for "happened".

  1. 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

  2. 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

  3. 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

  4. 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

  5. The Wrong Shot: Error Disclosure | PSNet

    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

  6. Psn-Pdf (pdf file)

    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

  7. 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?

  8. Premortem Assessment | Agency for Healthcare Research and Quality

    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?

  9. What happens when things go wrong? | PSNet

    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. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X…

  10. What happens when healthcare innovations collide? | PSNet

    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. Copy Citation Format: DOI Google S…

  11. 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.

  12. 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?

  13. 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?

  14. 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

  15. 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.

  16. 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.

  17. 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”?

  18. 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?

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49858/psn-pdf
    April 01, 2019 - What Happened on Telemetry? April 1, 2019 Sandau KE, Funk M. What Happened on Telemetry? … https://psnet.ahrq.gov/web-mm/what-happened-telemetry Case Objectives Describe current hospital practices … https://psnet.ahrq.gov/web-mm/what-happened-telemetry Continuous monitoring of a patient's electrocardiographic … The nurse manager for the unit led a root cause analysis to determine what had happened.

  20. 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
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