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Showing results for "happened".

81. 155-Performing-Premortem-Project-Assessment (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/155-performing-premortem-project-assessment.docx
    October 01, 2024 - They review what happened and say, “If we had only known that this was the reason that this project failed … They found that if you can look at an upcoming event as though it has already happened, it makes it easier … Ask your team: What could have happened? What could have gone wrong? … What could have happened? What can we do to keep it from happening?

82. Silence A Commentary | Agency for Healthcare Research and Quality
    www.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,

83. Module 5: Response and Disclosure | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/notes.html
    August 01, 2022 - Slide 11 Say: The Disclosure Checklist includes: What happened–identify the adverse … event early in the disclosure, explain what happened in a way that is easy to understand, explain what … is known about why the adverse event occurred, but DO NOT guess or assume anything about what happened … Tell the patient what should have happened. … This question is often a stand-in for "How could this have happened?"

84. Accessible Facilitator Guide: Learn From Defects for Sustainability (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_learn_from_defects_facnotes.docx
    December 01, 2017 - The first question is, what happened? … Slide 9 What Happened? ASK: What happened? SAY: We recommend walking the process. … Slide 10 What Happened? ASK: Who was involved? What were the actions? … What happened that actually may have helped ameliorate the situation? … SAY: Armed with knowledge about what happened and why it happened, it’s time to build your interventions

85. Sustainability: Learning From Defects: Facilitator Notes | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/surgery/modules/sustainability/learn-from-defects-fac-notes.html
    December 01, 2017 - The first question is, what happened? … Slide 10: What Happened? Ask: What happened? Say: We recommend walking the process. … Slide 11: What Happened? Ask: Who was involved? What were the actions?  … What happened that actually may have helped ameliorate the situation? … Say: Armed with knowledge about what happened and why it happened, it’s time to build your interventions

86. Seeking answers, hearing silence. | PSNet
    psnet.ahrq.gov/issue/seeking-answers-hearing-silence
    October 09, 2024 - whose daughter died from medical error and the resistance she faced when trying to understand what happened … July 5, 2023 Deny, Dismiss, Dehumanise: What Happened When I Went to Hospital.

87. PowerPoint Presentation
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/module5-response-disclosure-notes.pptx
    August 21, 2015 - What happened exactly? What are the implications for the patient’s health? Why did it happen? … Module 5 12 The Disclosure Checklist includes: What happened–identify the adverse event early in the … the adverse event occurred, but DO NOT guess or assume anything about what happened. … Tell the patient what should have happened. … This question is often a stand-in for “How could this have happened?”

88. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/33878/psn-pdf
    April 01, 2019 - But that's not what has happened. There are now many lawyers who specialize in ACC law. … error and this happened to you." … So say, "My bad that this happened." … She expressed how terrible she felt about what had happened. … He said to his mother, I'm really upset by what happened to my sister.

89. Coaching-Facnotes (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/coaching/coaching-facnotes.docx
    May 01, 2017 - Ideally, team members do this by reflecting on what has happened. … The question should express genuine curiosity about what happened. … · “I am curious, what do you think happened?” · “How did that make you feel?” … Can you help me understand what happened?” … I’m curious, what do you think happened?”

90. 109-Performing-Premortem-Project-Assessment-Fg (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/109-performing-premortem-project-assessment-fg.docx
    April 01, 2025 - They review what happened and say, “If we had only known that this was the reason that this project failed … They found that if you can look at an upcoming event as though it has already happened, it makes it easier … Ask your team: What could have happened? What could have gone wrong? … What could have happened? What can we do to keep it from happening?

91. In Conversation With… … Jennifer Schulz Moore, LLB, MA, PhD | PSNet
    psnet.ahrq.gov/perspective/conversation-jennifer-schulz-moore-llb-ma-phd
    February 26, 2025 - But that's not what has happened. There are now many lawyers who specialize in ACC law. … error and this happened to you." … So say, "My bad that this happened." … She expressed how terrible she felt about what had happened. … He said to his mother, I'm really upset by what happened to my sister.

92. Morning Briefing and Shadowing (Slide Presentation) | Agency for Healthcare Research and Quality
    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?

93. 023-Ss-Cusp-Learning-From-Defects-Fg (doc file)
    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?

94. 004-Cusp-Learning-From-Defects (doc file)
    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?

95. Sued for misdiagnosis? It could happen to you. | PSNet
    psnet.ahrq.gov/issue/sued-misdiagnosis-it-could-happen-you
    February 07, 2024 - Commentary Sued for misdiagnosis? It could happen to you. Citation Text: Lippman H, Davenport J. Sued for misdiagnosis? It could happen to you. J Fam Pract. 2010;59(9):498-508. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pu…

96. Videos of simulated after action reviews: a training resource to support social and inclusive learning from patient safety events. | PSNet
    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.

97. Administering the CAHPS Child Hospital Narrative Item Set (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/item-sets/administering-child-hcahps-narrative-items.pdf
    November 01, 2023 - s hospital stay can be an intense experience; please take as much time as you need to tell us what happened … Please explain what happened, how it happened, and how it felt. H-PN2. … Please explain what happened, how it happened, and how it felt. H-PN3.

98. PowerPoint Presentation
    www.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.

99. Chapter 1. Background | Agency for Healthcare Research and Quality
    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?

100. The wrong goodbye. | PSNet
     psnet.ahrq.gov/issue/wrong-goodbye
     October 05, 2022 - How could it have happened? … How could it have happened?