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Total Results: 4,079 records

Showing results for "happened".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41993/psn-pdf
    April 21, 2015 - available, and 97% of participants reported that they would want the checklist used if one of these crises happened

  2. DESC Technique for Conflict With Residents and Families (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/DESC-technique.pdf
    June 01, 2021 - She is not acting like herself today, and the last time this happened, someone told you she had a UTI

  3. 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.

  4. 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

  5. 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?

  6. New Mexico IMPaCT: Catalyzing Community Health Transformation in Kansas | Agency for Healthcare Research and Quality

    www.ahrq.gov/ncepcr/research-transform-primary-care/transform/impactgrants/impact-ks-success-story.html
    April 01, 2015 - “We were motivated by collaborations that had happened between the University of New Mexico and New Mexico … cooperative extension folks at Kansas State to develop collaborations, which is not something that had happened

  7. 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?

  8. Misread Label | PSNet

    psnet.ahrq.gov/web-mm/misread-label
    August 28, 2024 - manufacturer and presented in similar packaging, it may be slightly easier to understand how the error happened … medication, found that patients wanted disclosure of all harmful errors and sought information about what happened … physicians disclosed the adverse event, they often avoided stating that an error had occurred, why it happened

  9. Patient and Family Engagement for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/pf-engagement-fac-guide.html
    July 01, 2023 - Providers communicate the facts of what happened and assure the patient and family that they will receive … A hospital committed to transparency offers an apology that the incident happened. … An explanation of what happened. A meaningful discussion of projected outcomes.

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49425/psn-pdf
    November 01, 2003 - manufacturer and presented in similar packaging, it may be slightly easier to understand how the error happened … medication, found that patients wanted disclosure of all harmful errors and sought information about what happened … physicians disclosed the adverse event, they often avoided stating that an error had occurred, why it happened

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/840174/psn-pdf
    August 28, 2024 - He confirmed that she understood what happened, including the miscommunication among operating room … patient’s death, she may have wondered about the facts of his care, possibly misinterpreting what happened … should also be reassured that a root cause analysis (RCA) will be carried out to determine exactly what happened … that is a good time to ask the widow to tell the attendees about her husband as they likely know what happened … conversation.html The latter explanation is particularly important, as most families want to know that what happened

  12. PowerPoint Presentation

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module6/module6-care-for-caregiver.pptx
    May 01, 2011 - I started to doubt myself… I thought maybe if I’d have done something another way, it wouldn’t have happened … anonymous second-victim: “Every single day for months, I’d walk in and think, ‘Everyone knows what happened … Develop understanding of what happened. Support individual(s) involved in event. … High-acuity areas have little time to integrate what has happened. Intense fear of the unknown. … Having time to integrate what has happened, especially in high-acuity areas such as emergency departments

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36836/psn-pdf
    January 29, 2015 - Their objectives included understanding what happened in Bristol, assessing the quality of care and

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44626/psn-pdf
    November 04, 2015 - The process begins with a preliminary investigation into what happened and who was involved, followed

  15. Missed CANDOR Implementation Opportunities. | PSNet

    psnet.ahrq.gov/web-mm/missed-candor-implementation-opportunities
    November 11, 2020 - He confirmed that she understood what happened, including the miscommunication among operating room team … the patient’s death, she may have wondered about the facts of his care, possibly misinterpreting what happened … also be reassured that a root cause analysis (RCA) will be carried out to determine exactly what happened … that is a good time to ask the widow to tell the attendees about her husband as they likely know what happened … The latter explanation is particularly important, as most families want to know that what happened to

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73145/psn-pdf
    April 28, 2021 - If there has been an infection, they will use that visit to go back and work out what happened, as the … When you go back and say, “well, what happened here,” it acts as another safeguard and allows us to … When a PD patient gets peritonitis, nearly every time you can trace back and figure out what happened … That is some of the troubleshooting and evaluation we do to try to figure out what could have happened … What has happened, as I referenced before, is that the advent of Bluetooth technology has lessened the

  17. Implementing the New CAHPS Protocol for Obtaining Patient Comments About Their Care (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/implementing-new-protocol-transcript.pdf
    October 01, 2018 - Because before understanding what has actually happened to a patient we need to know what it is that … We probe, please explain what happened, how it happened and how it felt to you in order to get that complete … And again please explain what happened, how it happened and how it felt to you. … Is this something that happened once or is this something that happens to you often? … And how did what happened get brought about?

  18. Learning From Defects | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/tools/mrsa-prevention/toolkit/learning-from-defects.html
    October 01, 2024 - There are four key questions in the CUSP Learning From Defects process: What happened?

  19. Conducting a Morning Briefing | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/cusp/toolkit/morning-briefing.html
    December 01, 2012 - Briefing process What happened overnight that I need to know about?

  20. Resilience Engineering in Practice: a Guidebook. | PSNet

    psnet.ahrq.gov/issue/resilience-engineering-practice-guidebook
    February 06, 2019 - respond to disruptions , monitor their environment, anticipate future impacts, and learn from what happened
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