U.S. flag

An official website of the Department of Health & Human Services

AHRQ: Agency for Healthcare Research and Quality

Search AHRQ

For an exact phrase match, enclose search terms in double quotes.

Go to Advanced Search
Go to Basic Search

Results

Total Results: 1,692 records

Showing results for "happen".

  1. Psn-Pdf (pdf file)

    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

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850358/psn-pdf
    June 14, 2023 - What Happened to Patient Safety. June 14, 2023 Sheridan S. Turn on the Lights. Institute for Healthcare Improvement.  May 2023 https://psnet.ahrq.gov/issue/what-happened-patient-safety Patient engagement is an important component in patient safety. This episode from the Turn on the Lights podcast (hosted by I…

  3. 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.

  4. Psn-Pdf (pdf file)

    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.

  5. 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

  6. 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

  7. Psn-Pdf (pdf file)

    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. Uitgeverij van Brug: The Hague, The Netherlands; 2019. ISBN: 9789065232236. https://psnet.ahrq.gov/issue/deny-dismiss-dehumanise-what-happened-when-i-went-hospital Patient stories offer important insights regarding the impact m…

  8. 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?

  9. 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

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73222/psn-pdf
    May 05, 2021 - Fatal mistakes: why do ten-fold medication errors in children keep happening? May 5, 2021 Parry C. The Pharmaceutical Journal.  April 22 2021. https://psnet.ahrq.gov/issue/fatal-mistakes-why-do-ten-fold-medication-errors-children-keep-happening Weight-based prescribing in children harbors challenges to accura…

  11. 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

  12. 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

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848092/psn-pdf
    April 26, 2023 - Doctors must stop tuning out Black women. It happened to me, as a pregnant OB-GYN. April 26, 2023 Gillispie-Bell V. USA Today. April 14, 2023. https://psnet.ahrq.gov/issue/doctors-must-stop-tuning-out-black-women-it-happened-me-pregnant-ob-gyn Structural racism and implicit biases can lead to poor quality of care …

  14. 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

  15. In Conversation with Jessica Behrhorst about The Evolution of Root Cause Analysis | PSNet

    psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evolution-root-cause-analysis
    February 26, 2025 - “Why did it happen?” “What are we doing to keep it from happening again?” … direct causes of an adverse event and the systemic weaknesses that may have allowed the event to happen

  16. 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?”

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33670/psn-pdf
    July 01, 2008 - What then needs to happen is the institutions need to track what the solutions are, and they need to … serious incidents, called sentinel events, and any hospital board would like to see these things never happen … Wrong site surgeries are a pretty good example of this—they happen to every big institution a few times

  18. In Conversation with…Robert M. Wachter, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-withrobert-m-wachter-md
    October 01, 2008 - If you are going to promulgate a policy that either publicly reports adverse events that happen in hospitals … to be sure that the hospital is not being blamed, for lack of a better word, for things that didn't happen … Sometimes patients are sent to us because they've had bad things happen—they're very ill and it's our … That in fact, hospitals should be paying for things that shouldn't happen, and that this type of policy … DRG-like system where we will pay for a given diagnosis, I think it is inevitable that when adverse events happen

  19. 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

  20. 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 …
SHARE:
Facebook Twitter Print Facebook Share

Similar Terms:

Search the AHRQ Archive

Information and reports more than 5 years old may be found in the AHRQ Archive site.

Search Archive

Search Within A Specific AHRQ Site

You selected to view results for the following site:

View results from all sites