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psnet.ahrq.gov/node/852456/psn-pdf
August 16, 2023 - learning-mistakes-factors-influence-how-students-and-residents-learn-medical-errors
https://psnet.ahrq.gov/issue/when-bad-things-happen-training-medical-students-anticipate-aftermath-medical-errors
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psnet.ahrq.gov/node/72830/psn-pdf
March 10, 2021 - challenge to track medical errors that take place in the home environment, yet it is understood they
happen
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psnet.ahrq.gov/node/60154/psn-pdf
March 25, 2020 - systematic-review-and-evaluation-physiological-track-and-trigger-warning-systems-identifying
https://psnet.ahrq.gov/issue/hospitals-look-computers-predict-patient-emergencies-they-happen
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psnet.ahrq.gov/perspective/disclosure-medical-error
January 01, 2009 - Thus, these data do not necessarily speak to what will happen to liability if a physician's disclosure … We are going to do what it takes to make you better and make sure the same thing does not happen again … We also know very little about how patients want disclosure to happen in the moment. … organization are doing to mitigate the harm to that particular patient and fix the problem so it doesn't happen
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psnet.ahrq.gov/perspective/conversation-withthomas-h-gallagher-md
January 01, 2009 - We also know very little about how patients want disclosure to happen in the moment. … organization are doing to mitigate the harm to that particular patient and fix the problem so it doesn't happen … Thus, these data do not necessarily speak to what will happen to liability if a physician's disclosure … We are going to do what it takes to make you better and make sure the same thing does not happen again
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psnet.ahrq.gov/node/43513/psn-pdf
September 10, 2014 - questionable-hospital-chart-documentation-practices-physicians
https://psnet.ahrq.gov/issue/sued-misdiagnosis-it-could-happen-you
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psnet.ahrq.gov/node/34854/psn-pdf
March 28, 2005 - Dealing with medical errors when they happen--
instead of in court--can benefit doctors and patients
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psnet.ahrq.gov/node/865665/psn-pdf
April 24, 2024 - medical-students-experiences-perceptions-and-management-second-victim-interview-study
https://psnet.ahrq.gov/issue/when-bad-things-happen-training-medical-students-anticipate-aftermath-medical-errors
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psnet.ahrq.gov/node/33662/psn-pdf
January 01, 2008 - Sometimes safety improvements are generated when bad things happen to good people. … The
average size of a Tenet Hospital is about 150 beds, so these things happen infrequently. … then there would be, for example, the four things you or your unit can do, to make sure this doesn't happen … randomized controlled trial evidence that a particular safety
intervention works just isn't going to happen
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psnet.ahrq.gov/node/47757/psn-pdf
February 06, 2019 - Doctors make mistakes. A new documentary explores
what happens when they do—and how to fix it.
February 6, 2019
Park A. Time Magazine. January 24, 2019.
https://psnet.ahrq.gov/issue/doctors-make-mistakes-new-documentary-explores-what-happens-when-they-
do-and-how-fix-it
This news article reports on the documentar…
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psnet.ahrq.gov/node/46506/psn-pdf
October 11, 2017 - Getting Ahead of Harm Before It Happens: A Guide About
Proactive Analysis for Improving Surgical Care Safety.
October 11, 2017
Wiley K, Davies JM. Edmonton, AB: Canadian Patient Safety Institute; 2017.
https://psnet.ahrq.gov/issue/getting-ahead-harm-it-happens-guide-about-proactive-analysis-improving-
surgical-car…
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psnet.ahrq.gov/node/36499/psn-pdf
January 07, 2011 - Web-based reporting system to monitor types of
medication errors and near misses, determine when they happen
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psnet.ahrq.gov/node/50677/psn-pdf
November 20, 2019 - What Happens When Doctors Make Diagnostic Errors?
November 20, 2019
The Peoples Pharmacy. Show 1186: National Public Radio. October 24, 2019.
https://psnet.ahrq.gov/issue/what-happens-when-doctors-make-diagnostic-errors
Misdiagnosis growing area of concern in health care. This radio feature explores three commonly
…
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psnet.ahrq.gov/node/841305/psn-pdf
January 27, 2023 - It was always a draft because as
the day evolved, things would happen that changed that plan. … All patient care events happen in the context of other people and
other parts of the system. … It’s the idea that we think that work—like providing healthcare—will happen
a certain way, but when … work actually happens, people often have to make adjustments to make the work
happen effectively and
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psnet.ahrq.gov/node/33878/psn-pdf
April 01, 2019 - Politically, how were they able to make that happen?
JM: The history is interesting. … Often an investigation needs to happen to elucidate the facts if it's
a complex error.
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psnet.ahrq.gov/perspective/conversation-michael-cohen-rph-ms-scd-hon-0
October 24, 2021 - We thought for sure that many errors that might have happened in the past wouldn't happen. … We have some really dangerous errors that happen. … A lot of that can happen at the counseling stage, where there's some communication between the pharmacist … And what is the pharmacy chain doing to make sure that something like that doesn't happen?" … supervisor's fault for not addressing the issue to make it much more unlikely or even impossible to happen
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psnet.ahrq.gov/node/50719/psn-pdf
December 04, 2019 - A lot happens when you report a hazard or error to
ISMP—there’s no “black hole” here!
December 4, 2019
ISMP Medication Safety Alert! Acute Care Edition. November 7, 2019
https://psnet.ahrq.gov/issue/lot-happens-when-you-report-hazard-or-error-ismp-theres-no-black-hole-here
The reporting and analysis of incidents i…
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psnet.ahrq.gov/node/33789/psn-pdf
August 01, 2015 - Interoperability, systems
that can talk to each other, I don't think will happen on its own in that … or in some cases
actually detrimental to making it happen. … Government has a role to convene and build incentives and
maybe requirements to make it happen. … The market will not make privacy and security happen well enough
by itself. … Some of that will happen
with the same changes that promote interoperability.
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psnet.ahrq.gov/node/73534/psn-pdf
July 28, 2021 - its-big-part-being-good-surgeons-surgical-trainees-perceptions-error-recovery-operating-room
https://psnet.ahrq.gov/issue/surgical-errors-happen-are-learners-trained-recover-them-survey-north-american-surgical
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psnet.ahrq.gov/node/844047/psn-pdf
February 08, 2023 - failure, the process of allowing or interrupting failure, and how they decide to allow failure to
happen