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Total Results: 4,079 records

Showing results for "happened".

221. 110-Ss-Lfd-Sample (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/110-ss-lfd-sample.docx
     April 01, 2025 - Provide a clear, thorough, and objective explanation of what happened. II. … What Happened? Reconstruct the timeline and explain what happened.

222. Service members are left in dark on health errors. | PSNet
     psnet.ahrq.gov/issue/service-members-are-left-dark-health-errors
     July 09, 2014 - highlights how insufficient transparency can prevent patients and their families from learning about what happened

223. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33857/psn-pdf
     July 01, 2012 - Had that not happened, what do you think the history of that intellectual and policy argument would have … DB: I don't think anything would have happened for many years thereafter. … RW: Some have made the argument that it might have happened a bit more slowly, but it would have happened … because of the value pressures and it might have happened more organically, for better or worse. … The wide use of patient portals would never have happened without Meaningful Use requirements because

224. In Conversation With… David Blumenthal, MD, MPP | PSNet
     psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp-0
     March 27, 2024 - Had that not happened, what do you think the history of that intellectual and policy argument would have … DB : I don't think anything would have happened for many years thereafter. … RW : Some have made the argument that it might have happened a bit more slowly, but it would have happened … because of the value pressures and it might have happened more organically, for better or worse. … The wide use of patient portals would never have happened without Meaningful Use requirements because

225. Conceptualising learning from resilient performance: a scoping literature review. | PSNet
     psnet.ahrq.gov/issue/conceptualising-learning-resilient-performance-scoping-literature-review
     October 09, 2024 - Descriptions include knowing what has happened; learning from the factual; learning from experience;

226. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/088-or-traffic.pptx
     April 01, 2025 - Prevention | Surgical Services OR Traffic 12 Case Example: Using the Learning From Defects Tool What happened … Services AHRQ Safety Program for MRSA Prevention | Surgical Services OR Traffic Case Example: What Happened

227. Sensemaking and Learn from Defects for Perinatal Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.pdf
     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.

228. Establishing a Program of In Situ Simulations: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/situ/simulation-slides.html
     July 01, 2023 - Slide 18: Debriefing: Describe What Happened First, each participant states their name, role, and … Slide 19: Debriefing: Describe What Happened It is important for the participants to realize it … Measure 1 Processes (Measures of Performance): Explain how and why certain outcomes may have happened

229. New Mexico IMPaCT: Catalyzing Community Health Transformation in Kansas (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/tpc/impact-ks-success-story.pdf
     April 01, 2015 - “We were motivated by collaborations that had happened between the University of New Mexico and New … cooperative extension folks at Kansas State to develop collaborations, which is not something that had happened

230. National Review of Maternity Services in England 2022 to 2024. | PSNet
     psnet.ahrq.gov/issue/national-review-maternity-services-england-2022-2024
     November 13, 2024 - It happened to me, as a pregnant OB-GYN.

231. Job Aid: “Last 10 Patients” Chart Audit (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/job-aid-last10-patients-audit.pdf
     June 02, 2025 - ago, care may not reflect current processes, and clinicians and staff may not be able to recall what happened

232. What is Patient Experience and How Does CAHPS Measure It? (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/primer-patient-experience.pdf
     June 02, 2025 - Patient experience refers to what happened in a health care setting.

233. Recognizing Excellence in Diagnosis. | PSNet
     psnet.ahrq.gov/issue/recognizing-excellence-diagnosis
     November 03, 2023 - June 8, 2023 Events that inspired change: the importance of sharing what happened to

234. 200 epidural blunders admitted after three women die. | PSNet
     psnet.ahrq.gov/issue/200-epidural-blunders-admitted-after-three-women-die
     March 18, 2020 - How could it have happened?

235. In Conversation with...Albert Wu, MD, MPH | PSNet
     psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph
     February 26, 2025 - So there's no way of knowing what has happened. … And this happened after a lengthy root cause analysis, which took perhaps 100 hours to perform. … And at every meeting, the board should also track what had happened to the previous quarter's or previous … year's root cause analyses and recommendations, and again, if possible, what has happened to that kind

236. Transcript: How To Have Difficult Conversations With Colleagues Around Infection Prevention Practices (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/difficult-conversations-transcript.pdf
     April 01, 2022 - needs to be experts on this because they're the ones that can see where the conversations should have happened … Maybe there's improvement in how it happened, but the essence of the conversation was important.

237. In Conversation with…Robert M. Wachter, MD | PSNet
     psnet.ahrq.gov/perspective/conversation-withrobert-m-wachter-md
     October 01, 2008 - That was appropriate when the adverse events just happened and they cost institutions more money to take … So if the hospital is going to be tagged with an adverse event that happened at another place, that's … advance directives and other elements of complex care that take time, where the metric of whether it happened … Under the old payment system, when the adverse event happened, the hospital would get paid an extra 50% … And I think that's happened.

238. The fading art of the physical exam. | PSNet
     psnet.ahrq.gov/issue/fading-art-physical-exam
     July 10, 2024 - August 28, 2019 Deny, Dismiss, Dehumanise: What Happened When I Went to Hospital.

239. Learning from tragedy: the Julia Berg story. | PSNet
     psnet.ahrq.gov/issue/learning-tragedy-julia-berg-story
     October 28, 2020 - piece includes the perspectives of the patient's family and from the organization regarding what happened

240. Pf-Engagement-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/pf-engagement-facilitator-guide.docx
     May 01, 2017 - 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. … communicated to the patient and family: An apology for any unreasonable care An explanation of what happened