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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-patient-narrative-martino.pdf
June 01, 2021 - Please
explain what happened, how it happened, and how it
felt to you. … Please
explain what happened, how it happened, and how it
felt to you. … Please explain what happened, how it happened,
and how it felt to you. … If so, please explain what
happened, how it happened, and how it felt to you. … Please explain what
happened, how it happened, and how it felt to you.
-
www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-patient-narrative-martino.pdf
June 01, 2021 - Please
explain what happened, how it happened, and how it
felt to you. … Please
explain what happened, how it happened, and how it
felt to you. … Please explain what happened, how it happened,
and how it felt to you. … If so, please explain what
happened, how it happened, and how it felt to you. … Please explain what
happened, how it happened, and how it felt to you.
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-patient-narrative-martino.pdf
June 01, 2021 - Please
explain what happened, how it happened, and how it
felt to you. … Please
explain what happened, how it happened, and how it
felt to you. … Please explain what happened, how it happened,
and how it felt to you. … If so, please explain what
happened, how it happened, and how it felt to you. … Please explain what
happened, how it happened, and how it felt to you.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/clabsi-learning-from-defects_revised.docx
April 01, 2022 - This worksheet will help your team learn what happened, identify the factors that may have contributed … Record Number: ____________
Date of Birth: _______________
What Happened … In a brief description, document what happened from at least two different staff members. … control and nursing staff are recommended, but others on the team who can give clear descriptions of what happened … Summarize what happened to cause the defect by answering the following questions.
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psnet.ahrq.gov/node/851071/psn-pdf
June 28, 2023 - Inside the preventable deaths that happened within a
prominent transplant center. … https://psnet.ahrq.gov/issue/inside-preventable-deaths-happened-within-prominent-transplant-center
Medical … https://psnet.ahrq.gov/issue/inside-preventable-deaths-happened-within-prominent-transplant-center
https
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/item-sets/CG/supplemental-elicitation-protocol-cgcahps-child_2358-7a.docx
December 01, 2016 - Please explain what happened, how it happened, and how it felt to you.
C-PN4. … Please explain what happened, how it happened, and how it felt to you.
C-PN5.
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psnet.ahrq.gov/node/50606/psn-pdf
October 30, 2019 - How could it have happened?
October 30, 2019
Healy J, Farr I, Feiger L, Duffy C. New York Times. … https://psnet.ahrq.gov/issue/one-doctor-25-deaths-how-could-it-have-happened
Systemic failures persistently … https://psnet.ahrq.gov/issue/one-doctor-25-deaths-how-could-it-have-happened
https://psnet.ahrq.gov/issue
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psnet.ahrq.gov/issue/medication-mix-what-happened-vanderbilt-and-how-it-impacts-health-care-providers
March 18, 2020 - Commentary
Medication mix-up: what happened at Vanderbilt and how it impacts health … Citation Text:
Medication mix-up: what happened at Vanderbilt and how it impacts health care providers … Cite
Citation
Citation Text:
Medication mix-up: what happened
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psnet.ahrq.gov/node/850358/psn-pdf
June 14, 2023 - What Happened to Patient Safety.
June 14, 2023
Sheridan S. Turn on the Lights. … May 2023
https://psnet.ahrq.gov/issue/what-happened-patient-safety
Patient engagement is an … https://psnet.ahrq.gov/issue/what-happened-patient-safety
https://psnet.ahrq.gov/primer/patient-engagement-and-safety
-
psnet.ahrq.gov/node/47885/psn-pdf
May 01, 2019 - Deny, Dismiss, Dehumanise: What Happened When I
Went to Hospital.
May 1, 2019
Cullen A. … https://psnet.ahrq.gov/issue/deny-dismiss-dehumanise-what-happened-when-i-went-hospital
Patient stories … https://psnet.ahrq.gov/issue/deny-dismiss-dehumanise-what-happened-when-i-went-hospital
https://psnet.ahrq.gov
-
psnet.ahrq.gov/node/848092/psn-pdf
April 26, 2023 - It happened
to me, as a pregnant OB-GYN.
April 26, 2023
Gillispie-Bell V. USA Today. … https://psnet.ahrq.gov/issue/doctors-must-stop-tuning-out-black-women-it-happened-me-pregnant-ob-gyn … https://psnet.ahrq.gov/issue/doctors-must-stop-tuning-out-black-women-it-happened-me-pregnant-ob-gyn
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psnet.ahrq.gov/issue/doctors-must-stop-tuning-out-black-women-it-happened-me-pregnant-ob-gyn
June 24, 2020 - It happened to me, as a pregnant OB-GYN. … It happened to me, as a pregnant OB-GYN. Gillispie-Bell V. USA Today. April 14, 2023. … It happened to me, as a pregnant OB-GYN. Gillispie-Bell V. USA Today. April 14, 2023.
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psnet.ahrq.gov/issue/drug-error-eskenazi-hospital-killed-prominent-cancer-researcher-heres-how-it-happened
September 09, 2015 - Here's how it happened. … Here's how it happened. Evans T. Indianapolis Star. October 30, 2020. … Here's how it happened. Evans T. Indianapolis Star. October 30, 2020.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/defects.docx
May 01, 2017 - What happened? (brief description)
2. Why did it happen? … negative factors
What happened to cause the defect?
3. What did we do to manage it?
4. … Has it happened again?
With whom will we share our learning?
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module2/defects.docx
March 01, 2017 - What happened? (brief description)
2. Why did it happen? … negative factors
What happened to cause the defect?
3. What did we do to manage it?
4. … Has it happened again?
With whom will we share our learning?
-
www.ahrq.gov/hai/tools/surgery/modules/sustainability/learn-from-defects-slides.html
December 01, 2017 - Slide 10: What Happened?
Walk the process. … Reconstruct the timeline and reenact what happened. … Slide 11: What Happened?
Image: Questions to ask to learn what happened. … Questions are in color boxes with arrows pointing to a large circle in the center that reads, "What Happened … What happened that had a good outcome?
What happened that had a bad outcome?
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www.ahrq.gov/cahps/surveys-guidance/item-sets/cg/suppl-narrative-items-cg-survey30-adult.html
August 01, 2021 - Please explain what happened, how it happened, and how it felt to you. … If so, please explain what happened, how it happened, and how it felt to you.
-
www.ahrq.gov/patient-safety/settings/hospital/candor/modules/checklist5.html
August 01, 2022 - patient/family that the organization will conduct an Event Investigation and Analysis to understand what happened … LISTEN AND EMPATHIZE THROUGHOUT
Assess the patient's/family's understanding of what happened … EXPLAIN THE FACTS
What happened?
… Explain what happened in a way that is easy to understand.
… IF THE EVENT WAS PREVENTABLE (DUE TO ERROR)
Tell the patient/family what should have happened
-
www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/implementation-guide/app-j.html
May 01, 2017 - I am curious, what do you think happened?
How did that make you feel? … I wonder what you think happened? … I am curious, what do you think happened?
How did that make you feel? … I am curious, what do you think happened?
How did that make you feel? … I am curious, what do you think happened?
How did that make you feel?
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/implementation-guide/appendix-j.pdf
April 13, 2017 - I am curious, what do you think happened?
How did that make you feel? … I wonder what you think happened? … I am curious, what do you think happened?
How did that make you feel? … I am curious, what do you think happened?
How did that make you feel? … I am curious, what do you think happened?
How did that make you feel?
Coaching Tool