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Showing results for "happened".

221. Coaching Clinical Teams Module: Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/coaching-fac-notes.html
     October 01, 2020 - Ideally, team members do this by reflecting on what has happened. … The question should express genuine curiosity about what happened. … "I am curious, what do you think happened?" "How did that make you feel?" … Can you help me understand what happened?" … I’m curious, what do you think happened?”

222. Learn From Defects Tool—Perioperative Setting | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/hai/tools/surgery/tools/applying-cusp/learn-from-defects.html
     December 01, 2017 - Too few perioperative teams take the opportunity to learn how the defect happened at a systems level, … What happened? Provide a clear, thorough, and objective explanation of what happened. … What happened? Reconstruct the timeline and explain what happened. … Provide a clear, thorough, and objective explanation of what happened. Why did it happen? … What happened? Reconstruct the timeline and explain what happened.

223. Module 5: Response and Disclosure | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/notes.html
     August 01, 2022 - Slide 11 Say: The Disclosure Checklist includes: What happened–identify the adverse … event early in the disclosure, explain what happened in a way that is easy to understand, explain what … is known about why the adverse event occurred, but DO NOT guess or assume anything about what happened … Tell the patient what should have happened. … This question is often a stand-in for "How could this have happened?"

224. Seeking answers, hearing silence. | PSNet
     psnet.ahrq.gov/issue/seeking-answers-hearing-silence
     October 09, 2024 - whose daughter died from medical error and the resistance she faced when trying to understand what happened … July 5, 2023 Deny, Dismiss, Dehumanise: What Happened When I Went to Hospital.

225. Sustainability: Learning From Defects: Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/surgery/modules/sustainability/learn-from-defects-fac-notes.html
     December 01, 2017 - The first question is, what happened? … Slide 10: What Happened? Ask: What happened? Say: We recommend walking the process. … Slide 11: What Happened? Ask: Who was involved? What were the actions?  … What happened that actually may have helped ameliorate the situation? … Say: Armed with knowledge about what happened and why it happened, it’s time to build your interventions

226. Accessible Facilitator Guide: Learn From Defects for Sustainability (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_learn_from_defects_facnotes.docx
     December 01, 2017 - The first question is, what happened? … Slide 9 What Happened? ASK: What happened? SAY: We recommend walking the process. … Slide 10 What Happened? ASK: Who was involved? What were the actions? … What happened that actually may have helped ameliorate the situation? … SAY: Armed with knowledge about what happened and why it happened, it’s time to build your interventions

227. Presentation: Program Overview
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/learn-from-defects-slides.pptx
     January 01, 2017 - staff Learn From Defects ‹#› AHRQ Safety Program for Mechanically Ventilated Patients 11 What Happened … Learn From Defects ‹#› AHRQ Safety Program for Mechanically Ventilated Patients 13 What Happened … What happened that had a good outcome? … Reconstruct the timeline and explain what happened Consider recreating to make defect real Visualization … ” of a defect—including the values, attitudes, and beliefs—in order to create a lasting change What Happened

228. Learn From Defects Tool Worksheet: Catheter-Associated Urinary Tract Infection (CAUTI) (pdf file)
     www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cauti-learning-from-defects.pdf
     April 01, 2022 - This worksheet will help your team learn what happened, identify the factors that may have contributed … _______________________ Medical Record Number: ____________ Date of Birth: _______________ What Happened … The following questions will ask more details about what happened with the patient with documented … Summarize what happened to cause the defect by answering the following questions.

229. Learn From Defects Tool Worksheet: Catheter-Associated Urinary Tract Infection (CAUTI) (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cauti-learning-from-defects.pdf
     April 01, 2022 - This worksheet will help your team learn what happened, identify the factors that may have contributed … _______________________ Medical Record Number: ____________ Date of Birth: _______________ What Happened … The following questions will ask more details about what happened with the patient with documented … Summarize what happened to cause the defect by answering the following questions.

230. Disclosure Checklist | Agency for Healthcare Research and Quality
     healthcare411.ahrq.gov/patient-safety/settings/hospital/candor/modules/checklist5.html
     August 01, 2022 - patient/family that the organization will conduct an Event Investigation and Analysis to understand what happened … LISTEN AND EMPATHIZE THROUGHOUT   Assess the patient's/family's understanding of what happened … EXPLAIN THE FACTS   What happened?   … Explain what happened in a way that is easy to understand.   … IF THE EVENT WAS PREVENTABLE (DUE TO ERROR)   Tell the patient/family what should have happened

231. Disclosure Checklist | Agency for Healthcare Research and Quality
     cahps.ahrq.gov/patient-safety/settings/hospital/candor/modules/checklist5.html
     August 01, 2022 - patient/family that the organization will conduct an Event Investigation and Analysis to understand what happened … LISTEN AND EMPATHIZE THROUGHOUT   Assess the patient's/family's understanding of what happened … EXPLAIN THE FACTS   What happened?   … Explain what happened in a way that is easy to understand.   … IF THE EVENT WAS PREVENTABLE (DUE TO ERROR)   Tell the patient/family what should have happened

232. Disclosure Checklist | Agency for Healthcare Research and Quality
     monahrq.ahrq.gov/patient-safety/settings/hospital/candor/modules/checklist5.html
     August 01, 2022 - patient/family that the organization will conduct an Event Investigation and Analysis to understand what happened … LISTEN AND EMPATHIZE THROUGHOUT   Assess the patient's/family's understanding of what happened … EXPLAIN THE FACTS   What happened?   … Explain what happened in a way that is easy to understand.   … IF THE EVENT WAS PREVENTABLE (DUE TO ERROR)   Tell the patient/family what should have happened

233. Disclosure Checklist | Agency for Healthcare Research and Quality
     talkingquality.ahrq.gov/patient-safety/settings/hospital/candor/modules/checklist5.html
     August 01, 2022 - patient/family that the organization will conduct an Event Investigation and Analysis to understand what happened … LISTEN AND EMPATHIZE THROUGHOUT   Assess the patient's/family's understanding of what happened … EXPLAIN THE FACTS   What happened?   … Explain what happened in a way that is easy to understand.   … IF THE EVENT WAS PREVENTABLE (DUE TO ERROR)   Tell the patient/family what should have happened

234. Disclosure Checklist | Agency for Healthcare Research and Quality
     patientregistry.ahrq.gov/patient-safety/settings/hospital/candor/modules/checklist5.html
     August 01, 2022 - patient/family that the organization will conduct an Event Investigation and Analysis to understand what happened … LISTEN AND EMPATHIZE THROUGHOUT   Assess the patient's/family's understanding of what happened … EXPLAIN THE FACTS   What happened?   … Explain what happened in a way that is easy to understand.   … IF THE EVENT WAS PREVENTABLE (DUE TO ERROR)   Tell the patient/family what should have happened

235. Disclosure Checklist | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/modules/checklist5.html
     August 01, 2022 - patient/family that the organization will conduct an Event Investigation and Analysis to understand what happened … LISTEN AND EMPATHIZE THROUGHOUT   Assess the patient's/family's understanding of what happened … EXPLAIN THE FACTS   What happened?   … Explain what happened in a way that is easy to understand.   … IF THE EVENT WAS PREVENTABLE (DUE TO ERROR)   Tell the patient/family what should have happened

236. Understanding CAHPS Surveys: A Primer for New Users - CAHPS 101 (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/fry-administering.pdf
     January 27, 2023 - Patient experience refers to what happened in a health care setting. … Patient Satisfaction Experience • Whether something happened, or how often it happened • Frequency

237. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/module5-response-disclosure-notes.pptx
     August 21, 2015 - What happened exactly? What are the implications for the patient’s health? Why did it happen? … Module 5 12 The Disclosure Checklist includes: What happened–identify the adverse event early in the … the adverse event occurred, but DO NOT guess or assume anything about what happened. … Tell the patient what should have happened. … This question is often a stand-in for “How could this have happened?”

238. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33878/psn-pdf
     April 01, 2019 - But that's not what has happened. There are now many lawyers who specialize in ACC law. … error and this happened to you." … So say, "My bad that this happened." … She expressed how terrible she felt about what had happened. … He said to his mother, I'm really upset by what happened to my sister.

239. Learn From Defects in Care of Mechanically Ventilated Patients: Facilitator Guide | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/hai/tools/mvp/modules/cusp/learn-from-defects-fac-guide.html
     February 01, 2017 - Slide 12: What Happened? Say: Select a defect to explore. … Explore both the reasoning and the emotions behind what happened. … Slide 13: What Happened? … Say: Next, move on to why the defect happened. … If your team created a process map or a drawing to illustrate what happened, use it to map out what happened

240. 109-Performing-Premortem-Project-Assessment-Fg (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/109-performing-premortem-project-assessment-fg.docx
     April 01, 2025 - They review what happened and say, “If we had only known that this was the reason that this project failed … They found that if you can look at an upcoming event as though it has already happened, it makes it easier … Ask your team: What could have happened? What could have gone wrong? … What could have happened? What can we do to keep it from happening?