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www.ahrq.gov/hai/cusp/toolkit/content-calls/briefing-slides/slides.html
October 01, 2014 - What Happened Overnight That I Need to Know?
Slide 9. Where Should Rounds Begin?
Slide 10. … Morning Briefing Process
Three simple questions
What happened overnight that I need to know … What Happened Overnight That I Need to Know About?
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-ch-hospital-webcast-122223-martino.pdf
January 01, 2023 - Please explain what happened, how it happened,
and how it felt.
2. … Please explain what happened, how it
happened, and how it felt.
3.
-
talkingquality.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/hcbs-webcast-051623-ginsberg.pdf
June 21, 2023 - experiences with
their health care
► Patient experience vs patient satisfaction – whether something
happened … or how often it happened vs how patient felt about a
care encounter
8
CAHPS Program Activities
-
cahps.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/hcbs-webcast-051623-ginsberg.pdf
June 21, 2023 - experiences with
their health care
► Patient experience vs patient satisfaction – whether something
happened … or how often it happened vs how patient felt about a
care encounter
8
CAHPS Program Activities
-
pcmh.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/hcbs-webcast-051623-ginsberg.pdf
June 21, 2023 - experiences with
their health care
► Patient experience vs patient satisfaction – whether something
happened … or how often it happened vs how patient felt about a
care encounter
8
CAHPS Program Activities
-
pbrn.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/hcbs-webcast-051623-ginsberg.pdf
June 21, 2023 - experiences with
their health care
► Patient experience vs patient satisfaction – whether something
happened … or how often it happened vs how patient felt about a
care encounter
8
CAHPS Program Activities
-
monahrq.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/hcbs-webcast-051623-ginsberg.pdf
June 21, 2023 - experiences with
their health care
► Patient experience vs patient satisfaction – whether something
happened … or how often it happened vs how patient felt about a
care encounter
8
CAHPS Program Activities
-
healthcare411.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/hcbs-webcast-051623-ginsberg.pdf
June 21, 2023 - experiences with
their health care
► Patient experience vs patient satisfaction – whether something
happened … or how often it happened vs how patient felt about a
care encounter
8
CAHPS Program Activities
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/hcbs-webcast-051623-ginsberg.pdf
June 21, 2023 - experiences with
their health care
► Patient experience vs patient satisfaction – whether something
happened … or how often it happened vs how patient felt about a
care encounter
8
CAHPS Program Activities
-
psnet.ahrq.gov/issue/videos-simulated-after-action-reviews-training-resource-support-social-and-inclusive-learning
May 22, 2024 - Debriefing after significant clinical events helps affected staff develop a shared mental model of what happened … , why it happened, and how it can be prevented in the future.
-
psnet.ahrq.gov/issue/wrong-goodbye
October 05, 2022 - How could it have happened? … How could it have happened?
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/hcbs-2021-webcast-ahrq.pdf
January 01, 2021 - experiences with
their health care
► Patient experience vs patient satisfaction – whether something
happened … or how often it happened vs how patient felt about a
care encounter
9
CAHPS Program Activities
-
www.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/chapter1.html
August 01, 2022 - What happened?
Was the problem reported? To whom? … What happened when the problem was reported?
What caused the patient safety event to happen?
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/004-cusp-learning-from-defects.docx
October 01, 2024 - What happened?
2. Why did it happen?
3. … Slide 7
What Happened? … Slide 8
LFD Process: What Happened? … SAY:
To fully understand what happened, everyone involved should be considered and interviewed. … The following four questions help teams address and prevent defects system-wide:
· What happened?
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/023-ss-cusp-learning-from-defects-fg.docx
April 01, 2025 - What happened?
2. Why did it happen?
3. … Slide 7
Question One—What Happened? … Slide 8
Learning From Defects Process: What Happened? … SAY:
To fully understand what happened, everyone involved should be considered and interviewed. … The following four questions help teams address and prevent defects systemwide:
· What happened?
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects_facnotes.docx
December 01, 2017 - What happened that prevented the defect?
What happened that resulted in the defect? … Slide 13
What Happened? … Explain what happened. Make it visual. … Have participants explain what happened and why it happened. … Review what happened, why it happened, and what interventions were put in place.
-
ce.effectivehealthcare.ahrq.gov/hai/tools/mvp/modules/cusp/learn-from-defects-slides.html
February 01, 2017 - Image: Semi-circle shows the four questions that comprise the learning from defects process:
What happened … Slide 12: What Happened?
Select a defect to learn from. … Slide 13: What Happened?
Image: Chart depicting questions to ask to determine What Happened? … Slide 14: What Happened?
Reconstruct the timeline and explain what happened. … Refer back to any drawings your team used to illustrate what happened.
-
www.qualitymeasures.ahrq.gov/cahps/surveys-guidance/item-sets/cg/suppl-narrative-items-cg-survey30-child.html
August 01, 2021 - Please explain what happened, how it happened, and how it felt to you.
After C-PN2
C-PN4. … If so, please explain what happened, how it happened, and how it felt to you.
-
www.healthcare411.ahrq.gov/cahps/surveys-guidance/item-sets/cg/suppl-narrative-items-cg-survey30-child.html
August 01, 2021 - Please explain what happened, how it happened, and how it felt to you.
After C-PN2
C-PN4. … If so, please explain what happened, how it happened, and how it felt to you.
-
www.innovations.ahrq.gov/cahps/surveys-guidance/item-sets/cg/suppl-narrative-items-cg-survey30-child.html
August 01, 2021 - Please explain what happened, how it happened, and how it felt to you.
After C-PN2
C-PN4. … If so, please explain what happened, how it happened, and how it felt to you.