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Total Results: 1,692 records

Showing results for "happen".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866162/psn-pdf
    June 19, 2024 - Surgeon and surgical trainee experiences after adverse patient events. June 19, 2024 Ginzberg SP, Gasior JA, Passman JE, et al. Surgeon and surgical trainee experiences after adverse patient events. JAMA Netw Open. 2024;7(6):e2414329. doi:10.1001/jamanetworkopen.2024.14329. https://psnet.ahrq.gov/issue/surgeon-and…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866254/psn-pdf
    July 10, 2024 - Top Penn State Health surgeon warned leaders about transplant problems months before shutdown. Then he was let go. July 10, 2024 Massey W, Keith C. Spotlight PA: June 20, 2024. https://psnet.ahrq.gov/issue/top-penn-state-health-surgeon-warned-leaders-about-transplant-problems- months-shutdown-then Whistleblowers…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851067/psn-pdf
    June 28, 2023 - Assessing medication safety in settings not designated solely for pediatric patients. June 28, 2023 ISMP Medication Safety Alert! Acute care edition. June 15, 2023;28(12);1-5. https://psnet.ahrq.gov/issue/assessing-medication-safety-settings-not-designated-solely-pediatric-patients Pediatric patients are at increa…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853247/psn-pdf
    September 06, 2023 - Dangers and deaths around black pregnancies seen as a ‘completely preventable’ health crisis. September 6, 2023 West S. KFF Health News. August 24, 2023. https://psnet.ahrq.gov/issue/dangers-and-deaths-around-black-pregnancies-seen-completely-preventable- health-crisis The challenge of unsafe maternal care is gai…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853077/psn-pdf
    August 30, 2023 - 2022 John M. Eisenberg Patient Safety and Quality Awards. August 30, 2023 Jt Comm J Qual Patient Saf. 2023;49(9):435-450. https://psnet.ahrq.gov/issue/2022-john-m-eisenberg-patient-safety-and-quality-awards The legacy of AHRQ leader John Eisenberg, MD, still inspires safety improvement work decades after his pass…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48129/psn-pdf
    August 14, 2019 - When there's no one to whom an error can be disclosed, how should an error be handled? August 14, 2019 Chiu RG. When There's No One to Whom an Error Can Be Disclosed, How Should an Error Be Handled? AMA J Ethics. 2019;21(7):E553-558. doi:10.1001/amajethics.2019.553. https://psnet.ahrq.gov/issue/when-theres-no-one-…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33881/psn-pdf
    August 01, 2019 - In Conversation With… Erik Hollnagel, PhD June 1, 2019 In Conversation With… Erik Hollnagel, PhD. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-erik-hollnagel-phd Editor's note: Dr. Hollnagel is Senior Professor of Patient Safety at the University of Jönköping (Sweden) as well as Visiting…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33704/psn-pdf
    December 01, 2010 - open and honest, I'd ask them if you could use it within the organization to help ensure this doesn't happen

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49450/psn-pdf
    June 01, 2004 - The Wrong Shot: Error Disclosure June 1, 2004 Gallagher TH, Levinson W. The Wrong Shot: Error Disclosure. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure Case Objectives Describe the rationale for disclosing harmful errors to patients. Describe the specific information that patie…

  10. The Wrong Shot: Error Disclosure | PSNet

    psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure
    May 01, 2011 - SPOTLIGHT CASE The Wrong Shot: Error Disclosure Citation Text: Gallagher TH, Levinson W. The Wrong Shot: Error Disclosure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Sch…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/842779/psn-pdf
    January 12, 2011 - Resilience Engineering in Practice: a Guidebook. January 12, 2011 Hollnagel E, Parie?s J, Woods DD et al eds. Farnham UK; Ashgate, 2011. ISBN: 9781472420749 https://psnet.ahrq.gov/issue/resilience-engineering-practice-guidebook Safety-critical industries rely on organizational aptitude to respond to disr…

  12. In Conversation With… Robert Hirschtick, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-robert-hirschtick-md
    January 01, 2018 - We are testifying to things that didn't actually happen, physical exam findings that we didn't do, or

  13. In Conversation With… Susan Haas, MD, MSc | PSNet

    psnet.ahrq.gov/perspective/conversation-susan-haas-md-msc
    March 01, 2019 - And how can we make sure this doesn't happen again? … And that often doesn't happen, or it happens in a flurry of white coats being led around without getting

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47159/psn-pdf
    August 01, 2018 - Safety II behavior in a pediatric intensive care unit. August 1, 2018 Merandi J, Vannatta K, Davis T, et al. Safety II Behavior in a Pediatric Intensive Care Unit. Pediatrics. 2018;141(6):e20180018. doi:10.1542/peds.2018-0018. https://psnet.ahrq.gov/issue/safety-ii-behavior-pediatric-intensive-care-unit The tradit…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43849/psn-pdf
    January 28, 2015 - Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework. January 28, 2015 Singh H, Sittig DF. Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework. BMJ Qual Saf. 2015;24(2):103-110. doi:10.1136/bmjqs-2014-003675. https://psnet.ahrq.…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33816/psn-pdf
    October 01, 2016 - ways illustrating that a patient is at risk for a bad thing happening or a bad thing is starting to happen

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45455/psn-pdf
    June 29, 2017 - JAMA professionalism: disclosure of medical error. June 29, 2017 Levinson W, Yeung J, Ginsburg S. Disclosure of Medical Error. JAMA. 2016;316(7):764-5. doi:10.1001/jama.2016.9136. https://psnet.ahrq.gov/issue/jama-professionalism-disclosure-medical-error Disclosing medical errors to patients is essential for maint…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47636/psn-pdf
    December 12, 2018 - Learning from tragedy: the Julia Berg story. December 12, 2018 Graber ML, Berg D, Jerde W, et al. Learning from tragedy: the Julia Berg story. Diagnosis (Berl). 2018;5(4):257-266. doi:10.1515/dx-2018-0067. https://psnet.ahrq.gov/issue/learning-tragedy-julia-berg-story This commentary provides a clinical review of …

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34677/psn-pdf
    February 09, 2011 - Patients' and physicians' attitudes regarding the disclosure of medical errors. February 9, 2011 Gallagher TH, Waterman AD, Ebers AG, et al. Patients' and physicians' attitudes regarding the disclosure of medical errors. JAMA. 2003;289(8):1001-7. https://psnet.ahrq.gov/issue/patients-and-physicians-attitudes-regar…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49425/psn-pdf
    November 01, 2003 - Misread Label November 1, 2003 Franklin BD. Misread Label. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/misread-label The Case An infant was born with sluggish respirations. During labor the infant’s mother had received meperidine [Demerol, a pain medication], a narcotic with a half-life of 2.5-4.0 hours…
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