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www.talkingquality.ahrq.gov/patient-safety/reports/liability/silence.html
August 01, 2017 - However, what compounds the pain is when you are not told the truth about what has happened to your loved … There are four things patients and families want after medical harm has occurred: tell us what happened … are going to fix the problem, take responsibility, and apologize. 1 First, when we say "Tell us what happened … Second, we need to know that what happened to our loved one is not going to happen to anyone else. … No one should ever have to wait that long to find out answers about what happened to their loved one,
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www.cahps.ahrq.gov/patient-safety/reports/liability/silence.html
August 01, 2017 - However, what compounds the pain is when you are not told the truth about what has happened to your loved … There are four things patients and families want after medical harm has occurred: tell us what happened … are going to fix the problem, take responsibility, and apologize. 1 First, when we say "Tell us what happened … Second, we need to know that what happened to our loved one is not going to happen to anyone else. … No one should ever have to wait that long to find out answers about what happened to their loved one,
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www.healthcare411.ahrq.gov/patient-safety/reports/liability/silence.html
August 01, 2017 - However, what compounds the pain is when you are not told the truth about what has happened to your loved … There are four things patients and families want after medical harm has occurred: tell us what happened … are going to fix the problem, take responsibility, and apologize. 1 First, when we say "Tell us what happened … Second, we need to know that what happened to our loved one is not going to happen to anyone else. … No one should ever have to wait that long to find out answers about what happened to their loved one,
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www.cpsi.ahrq.gov/patient-safety/reports/liability/silence.html
August 01, 2017 - However, what compounds the pain is when you are not told the truth about what has happened to your loved … There are four things patients and families want after medical harm has occurred: tell us what happened … are going to fix the problem, take responsibility, and apologize. 1 First, when we say "Tell us what happened … Second, we need to know that what happened to our loved one is not going to happen to anyone else. … No one should ever have to wait that long to find out answers about what happened to their loved one,
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www.innovations.ahrq.gov/patient-safety/reports/liability/silence.html
August 01, 2017 - However, what compounds the pain is when you are not told the truth about what has happened to your loved … There are four things patients and families want after medical harm has occurred: tell us what happened … are going to fix the problem, take responsibility, and apologize. 1 First, when we say "Tell us what happened … Second, we need to know that what happened to our loved one is not going to happen to anyone else. … No one should ever have to wait that long to find out answers about what happened to their loved one,
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www.monahrq.ahrq.gov/patient-safety/reports/liability/silence.html
August 01, 2017 - However, what compounds the pain is when you are not told the truth about what has happened to your loved … There are four things patients and families want after medical harm has occurred: tell us what happened … are going to fix the problem, take responsibility, and apologize. 1 First, when we say "Tell us what happened … Second, we need to know that what happened to our loved one is not going to happen to anyone else. … No one should ever have to wait that long to find out answers about what happened to their loved one,
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ce.effectivehealthcare.ahrq.gov/patient-safety/reports/liability/silence.html
August 01, 2017 - However, what compounds the pain is when you are not told the truth about what has happened to your loved … There are four things patients and families want after medical harm has occurred: tell us what happened … are going to fix the problem, take responsibility, and apologize. 1 First, when we say "Tell us what happened … Second, we need to know that what happened to our loved one is not going to happen to anyone else. … No one should ever have to wait that long to find out answers about what happened to their loved one,
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www.ahrq.gov/ncepcr/data-resources/index.html
September 01, 2024 - CAHPS surveys measure what actually happened, or how often something happened to the patient in a healthcare
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/understand-sci-fac-guide.html
July 01, 2023 - When learning from defects, L&D 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 … What happened?
Why did it happen?
How will you reduce the risk of recurrence?
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psnet.ahrq.gov/node/33674/psn-pdf
February 01, 2009 - That was appropriate when the
adverse events just happened and they cost institutions more money to … 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 … And I think that's happened.
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www.ahrq.gov/teamstepps/instructor/essentials/coursemgmtappd.html
June 01, 2019 - Incorporate only vignettes and examples from events that actually happened. … What has happened up to this point?
What do you think about what happened?
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/situ/simulation-fac-guide.html
July 01, 2023 - Slide 18: Debriefing: Describe What Happened
Say:
The next step in the debrief process is to describe … what happened. … Slide 19: Debriefing: Describe What Happened
Say:
It is important for the facilitator to empathize … 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
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www.ahrq.gov/hai/cusp/modules/identify/index.html
July 01, 2018 - Video Segments
What Happened? (43 sec.)
Why Did It Happen? (34 sec.)
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psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph-0
March 24, 2025 - provider involved in the incident who feels in some way responsible and is emotionally traumatized by what happened … to provide clinical input at a time when the physician or nurse really needs help interpreting what happened … I think understanding what happened and what could have been done, or the lessons that might be learned … evaluating them, but who can provide an objective sophisticated assist to help them think through what happened … Rick Kidwell, our former hospital counsel, used to advise us to tell the patient what happened, be honest
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cusp-icu-notes.docx
April 01, 2022 - It requires ground truth of what actually happened and not presumptions about what might have happened … Remember to ask these four basic questions when considering a defect:
· What happened? … guide through the initial investigation for a defects analysis where the primary goal is to learn what happened … If your team created a process map, fishbone chart, or a drawing to illustrate what happened, use it … to map out what happened and include the "why" under each defect.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/simulation/simslides-update-62819.ppt
January 30, 2006 - 05.2 Page *
Page *
Simulation
Outcomes tend to be more quantifiable and answer the question “What happened … Sometimes referred to as measures of performance (MOPs)
Explain how and why certain outcomes may have happened … 05.2 Page *
Page *
Simulation
Phase 3
Debriefing
Introduce the debrief process
Describe what happened … learned
TEAMSTEPPS 05.2
Mod 1 05.2 Page *
Page *
Simulation
Description Phase
Recap of what happened … 05.2
Mod 1 05.2 Page *
Page *
Simulation
Analysis Phase
A systematic investigation of why things happened
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psnet.ahrq.gov/node/860386/psn-pdf
January 10, 2024 - Descriptions include knowing what has happened; learning from
the factual; learning from experience;
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psnet.ahrq.gov/node/73498/psn-pdf
July 14, 2021 - //psnet.ahrq.gov/issue/drug-error-eskenazi-hospital-killed-prominent-cancer-researcher-heres-how-it-happened
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-slides.pptx
June 01, 2021 - Decision Making
11
Changing the System
11
Problems Are Opportunities To Improve
12
What happened … Learning From Antibiotic-Associated Adverse Events Form
Changing the System
12
What Happened? … Explain what happened.
Put yourself in the place of those involved.
Try to understand.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-slides.pptx
June 01, 2021 - Decision Making
11
Changing the System
11
Problems Are Opportunities To Improve
12
What happened … Learning From Antibiotic-Associated Adverse Events Form
Changing the System
12
What Happened? … Explain what happened.
Put yourself in the place of those involved.
Try to understand.