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Showing results for "happen".

121. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50606/psn-pdf
     October 30, 2019 - One doctor. 25 deaths. How could it have happened? October 30, 2019 Healy J, Farr I, Feiger L, Duffy C. New York Times. October 11, 2019. https://psnet.ahrq.gov/issue/one-doctor-25-deaths-how-could-it-have-happened Systemic failures persistently undermine processes meant to keep patients safe. This news story discu…

122. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/851071/psn-pdf
     June 28, 2023 - Inside the preventable deaths that happened within a prominent transplant center. June 28, 2023 Blau M. ProPublica. June 14, 2023. https://psnet.ahrq.gov/issue/inside-preventable-deaths-happened-within-prominent-transplant-center Medical errors during organ transplants can have catastrophic consequences. This repo…

123. Safely Home: What Happens When People Leave Hospital Care Settings? | PSNet
     psnet.ahrq.gov/issue/safely-home-what-happens-when-people-leave-hospital-care-settings
     August 02, 2023 - Book/Report Safely Home: What Happens When People Leave Hospital Care Settings? Citation Text: Safely Home: What Happens When People Leave Hospital Care Settings? London, UK: Healthwatch England; July 2015. Copy Citation Save Save to your library Print D…

124. 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…

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/35766/psn-pdf
     March 02, 2011 - presented to illustrate the importance of bridging what happens at the bedside with what needs to happen

127. 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.

128. 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…

129. 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

130. 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

131. Deny, Dismiss, Dehumanise: What Happened When I Went to Hospital. | PSNet
     psnet.ahrq.gov/issue/deny-dismiss-dehumanise-what-happened-when-i-went-hospital
     September 09, 2015 - Book/Report Deny, Dismiss, Dehumanise: What Happened When I Went to Hospital. Citation Text: Deny, Dismiss, Dehumanise: What Happened When I Went to Hospital. Cullen A. Uitgeverij van Brug: The Hague, The Netherlands; 2019. ISBN: 9789065232236. Copy Citation Save …

132. 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?

133. 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

134. 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…

135. 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 …

136. 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

137. 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?”

138. 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

139. 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

140. In Conversation With… Lucian Leape, MD | PSNet
     psnet.ahrq.gov/perspective/conversation-lucian-leape-md
     June 12, 2019 - create a safe environment in an operating room, and that turns out to be difficult and doesn't just happen … Why can't you just make it happen? … They've learned over the last 10 years how to get this to happen. … Even though we haven't found the magic bullet to make it happen or pulled the right lever, I'm hopeful … Finally, I think the culture change we seek will happen faster than we expect.