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Showing results for "happen".

121. In Conversation With… Michael Cohen, RPh, MS, ScD (hon) | PSNet
     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

122. Psn-Pdf (pdf file)
     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

123. Psn-Pdf (pdf file)
     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

124. A lot happens when you report a hazard or error to ISMP—there’s no “black hole” here! | PSNet
     psnet.ahrq.gov/issue/lot-happens-when-you-report-hazard-or-error-ismp-theres-no-black-hole-here
     December 27, 2018 - Newspaper/Magazine Article A lot happens when you report a hazard or error to ISMP—there’s no “black hole” here! Citation Text: A lot happens when you report a hazard or error to ISMP—there’s no “black hole” here! ISMP Medication Safety Alert! Acute Care Edition. November 7, 2019 Cop…

125. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42346/psn-pdf
     June 10, 2018 - Fatal PCA adverse events continue to happen...better patient monitoring is essential to prevent harm

126. Psn-Pdf (pdf file)
     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.

127. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49468/psn-pdf
     December 16, 2004 - most sophisticated operating theaters and in the hands of highly trained surgeons—can such things happen … Or, in this case, almost happen? … Good systems do not just happen.

128. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/847060/psn-pdf
     January 01, 2001 - The Emperor’s New Clothes: Or Whatever Happened To “Human Error”? January 1, 2001 Hollnagel E, Amalberti R. Chapter In: Dekker SWA, ed.  Proceedings of the 4th International Workshop on Human Error, Safety and Systems Development. Linköping Sweden: Linköping University; 2001. https://psnet.ahrq.gov/issu…

129. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44327/psn-pdf
     August 26, 2015 - Safely Home: What Happens When People Leave Hospital Care Settings? August 26, 2015 London, UK: Healthwatch England; July 2015. https://psnet.ahrq.gov/issue/safely-home-what-happens-when-people-leave-hospital-care-settings Discharges are vulnerable periods for patients, often due to miscommunication, delays, and l…

130. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35766/psn-pdf
     March 02, 2011 - presented to illustrate the importance of bridging what happens at the bedside with what needs to happen

131. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45936/psn-pdf
     March 08, 2017 - using-information-external-errors-signal-clear-and-present-danger https://psnet.ahrq.gov/issue/could-it-happen-here-learning-other-organizations-safety-errors

132. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866583/psn-pdf
     August 28, 2024 - assessing-stops-framework-coping-intraoperative-errors-evidence-efficacy-hints-hubris-and https://psnet.ahrq.gov/issue/surgical-errors-happen-are-learners-trained-recover-them-survey-north-american-surgical

133. In Conversation With… … Jennifer Schulz Moore, LLB, MA, PhD | PSNet
     psnet.ahrq.gov/perspective/conversation-jennifer-schulz-moore-llb-ma-phd
     February 26, 2025 - 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.

134. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33686/psn-pdf
     August 01, 2009 - time at the right dose without asking the nurses to do endless workarounds to make sure that will all happen … Now without stopping the work, what could happen at that point is that the nurse does go procure the … RW: Does this not happen in health care because the nurse doesn't think about her work that way? … If you look at the financial market, what will happen is that for all the finger pointing that's going … Maybe the first measures are very simple: yes or no, did a never event happen?

135. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33688/psn-pdf
     October 01, 2009 - As you start reading through these forms, you start seeing the range of things that happen in health … out, but generally the institution did not make an effort to cover it up or to try to say it didn't happen … Part of the job of the media is not only to explain when these events happen but to try to put them … So I think it's an excuse to try to say that it's just the media attention, that these problems happen … Is the goal to make it better or at some point do you just say this is not going to happen?

136. In Conversation With... James P. Bagian, MD, PE | PSNet
     psnet.ahrq.gov/perspective/conversation-james-p-bagian-md-pe
     February 26, 2025 - The way I would look at it is to try to understand what happened, why did it happen, and what do you … Why did it happen? What are we going to do to prevent it in the future? … Our goal is to make sure that this cannot or is very unlikely to happen in the future and whether there's … Unfortunately, in today's health care industry there are many places where that doesn't happen.

137. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/850346/psn-pdf
     June 14, 2023 - coping-errors-operating-room-intraoperative-strategies-postoperative-strategies-and-sex https://psnet.ahrq.gov/issue/surgical-errors-happen-are-learners-trained-recover-them-survey-north-american-surgical

138. Medication mix-up: what happened at Vanderbilt and how it impacts health care providers. | PSNet
     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 care providers. Citation Text: Medication mix-up: what happened at Vanderbilt and how it impacts health care providers. Michel C, Talley C. J Health Life Sci Law. 2022;17(1):71 Copy Citation …

139. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33613/psn-pdf
     May 01, 2005 - How could such a terrible mistake happen to a team of highly qualified and dedicated individuals in … journey; the transition to an optimal culture of shared responsibility and accountability does not happen … have maintained the status quo, based on the mistaken premise that "mistakes like that could never happen

140. The Evolution of Root Cause Analysis | PSNet
     psnet.ahrq.gov/perspective/evolution-root-cause-analysis
     February 26, 2025 - direct causes of an adverse event and the systemic weaknesses that may have allowed the event to happen … “Why did it happen?” “What are we doing to keep it from happening again?”