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Showing results for "happened".

221. 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

222. 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

223. 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

224. 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

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. 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.

227. 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

228. 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.

229. 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

230. 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.

231. 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

232. 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.

233. 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?

234. 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

235. 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

236. Cusp Patient Family Engagement Facilitator Notes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/patfamilyengagement/CUSP_Patient_Family_Engagement_Facilitator_Notes.docx
     June 02, 2025 - critical, feedback, and focus on how to prevent a problem from reoccurring rather than focusing on what happened … Providers communicate the facts of what happened and assure the patient and family that they will receive … communicated to the patient and family: · An apology for any unreasonable care · An explanation of what happened … A hospital committed to transparency offers an apology that the incident happened.

237. Appendix C: The Health Care Safety Hotline: Operations Manual (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/hotline/healthcare-safety-hotline-appendixc.pdf
     July 01, 2015 - What happened? … Where do you believe it happened? 2.1c. When did it happen? 2.1d. … Why do you think this happened? 2.2 What is the name of the patient? … What happened? … Where do you believe it happened? 2.1c. When did it happen? 2.1d.

238. Simulation Facguide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/situ/simulation_facguide.docx
     May 01, 2017 - 16 SAY: The debrief process usually involves four steps: introducing the process, describing what happened … Slide 17 SAY: The next step in the debrief process is to describe what happened. … In discussing why things happened in the scenario as they did, the team should focus on critical aspects … They can explain how and why certain outcomes may have happened “Was the decision made right (correctly

239. CAHPS End of Life Care Survey (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/end-of-life/end-of-life-care-survey-english.pdf
     December 03, 2024 - Please explain what happened, where it happened, and how it felt to you and/or your family member.

240. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33670/psn-pdf
     July 01, 2008 - 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