-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Borowitz_4.pdf
January 22, 2008 - the patients on the wards
during the night shift meet with other members of the team to review what happened … Resident physicians indicated that something happened while they were on call for which they
were not … baseline assessment, the
residents indicated that in 40 of the 49 (82 percent) instances that something happened … During
the baseline assessment and after the intervention, sign-outs for nights when something happened … on nearly one-third of the nights they were on call, resident
physicians indicated that something happened
-
psnet.ahrq.gov/issue/life-mother-how-abortion-bans-lead-preventable-deaths
October 02, 2024 - It happened to me, as a pregnant OB-GYN.
-
psnet.ahrq.gov/issue/language-discordance-and-patient-care-babel
October 30, 2024 - It happened to me, as a pregnant OB-GYN.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/situ/simulation_facguide.pdf
May 01, 2017 - SAY:
The debrief process usually involves four
steps: introducing the process, describing
what happened … Program
of In Situ Simulations 11
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
-
www.ahrq.gov/hai/cusp/modules/understand/science-safety-notes.html
July 01, 2018 - When learning from defects, 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?
-
www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-3.html
June 01, 2023 - their safety concerns did so through a sequence of open-ended questions 18 :
Please tell us what happened … Considering only respondents for whom the diagnostic problem happened 3 or more years in the past, 28 … clinicians, scaffolding questions asked about these encounters and encouraged respondents to “explain what happened … , how it happened, and how it felt to you.”
-
psnet.ahrq.gov/issue/first-protect-patient-harm-applying-adult-learning-principles-patient-safety
June 09, 2011 - How could it have happened?
-
psnet.ahrq.gov/issue/unprotected-broken-promises-georgias-senior-care-industry
December 04, 2016 - How could it have happened?
-
psnet.ahrq.gov/issue/nurses-seek-reduce-long-hours-and-fatigue
March 08, 2019 - It happened to me, as a pregnant OB-GYN.
-
psnet.ahrq.gov/issue/first-do-less-harm-confronting-inconvenient-problems-patient-safety
March 29, 2007 - October 18, 2017
The Emperor’s New Clothes: Or Whatever Happened To “Human Error”?
-
psnet.ahrq.gov/issue/unwell-women-misdiagnosis-and-myth-man-made-world
March 20, 2019 - It happened to me, as a pregnant OB-GYN.
-
psnet.ahrq.gov/issue/robotic-assisted-surgery-focus-training-and-credentialing
January 07, 2015 - View More
Related Resources
Inside the preventable deaths that happened
-
psnet.ahrq.gov/issue/when-healthcare-hurts
January 15, 2014 - August 1, 2012
Deny, Dismiss, Dehumanise: What Happened When I Went to Hospital.
-
psnet.ahrq.gov/issue/why-doctors-still-offer-treatments-may-not-help
July 20, 2016 - How could it have happened?
-
psnet.ahrq.gov/node/33635/psn-pdf
July 01, 2006 - AF: You want to state what has happened, but you don't want to conjecture until you gain the information … I
think it's reasonable to say what happened, and then to be sure that the people fielding these issues … to the
public are skilled enough to say, "I can tell you that this is what has happened, and I can … We described
what happened.
-
digital.ahrq.gov/sites/default/files/docs/workflowtoolkit/Electronic_medical_record_checklist.pdf
December 18, 2021 - implementation
Talk about the level of service provided by the vendor
Discuss maintenance issues (what has happened
-
www.ahrq.gov/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/customer-service/strategy6q-custservice-standards.html
March 01, 2020 - "It's the doctor's fault and I can't believe that happened."
"I'm sorry that happened.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/pf-engagement-facilitator-guide.pdf
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
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/situ/simulation.pptx
May 01, 2017 - response.
17
AHRQ Safety Program for Perinatal Care
In Situ Simulations
17
Debriefing: Describe What Happened … 18
AHRQ Safety Program for Perinatal Care
In Situ Simulations
18
Debriefing: Describe What Happened … What To Measure1
Processes (Measures of Performance)
Explain how and why certain outcomes may have happened
-
psnet.ahrq.gov/issue/hospital-costs-associated-adverse-events-gynecological-oncology
March 09, 2022 - 2022
View More
Related Resources
Deny, Dismiss, Dehumanise: What Happened