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Showing results for "happen".

1261. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/863766/psn-pdf
      March 06, 2024 - Legacy: a Black Physician Reckons with Racism in Medicine. March 6, 2024 Blackstock U. New York, NY: Viking; 2024. ISBN: 9780593491287. https://psnet.ahrq.gov/issue/legacy-black-physician-reckons-racism-medicine The history of systemic racism is emerging to motivate health care equity and safety efforts. This memo…

1262. 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

1263. Use of an interactive, telephone-based self-management support program to identify adverse events among ambulatory diabetes patients. | PSNet
      psnet.ahrq.gov/issue/use-interactive-telephone-based-self-management-support-program-identify-adverse-events-among
      June 11, 2010 - Study Use of an interactive, telephone-based self-management support program to identify adverse events among ambulatory diabetes patients. Citation Text: Sarkar U, Handley MA, Gupta R, et al. Use of an interactive, telephone-based self-management support program to identify adverse ev…

1264. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36352/psn-pdf
      April 14, 2011 - Patient expectations of fair complaint handling in hospitals: empirical data. April 14, 2011 Friele RD, Sluijs EM. Patient expectations of fair complaint handling in hospitals: empirical data. BMC Health Serv Res. 2006;6:106. https://psnet.ahrq.gov/issue/patient-expectations-fair-complaint-handling-hospitals-empir…

1265. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50838/psn-pdf
      January 29, 2020 - Start the new year off right by preventing these top 10 medication errors and hazards. January 29, 2020 ISMP Medication Safety Alert! Acute care edition. January 16, 2020;26(2):1-6. https://psnet.ahrq.gov/issue/start-new-year-right-preventing-these-top-10-medication-errors-and-hazards Medication errors routinely c…

1266. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/854639/psn-pdf
      October 18, 2023 - Right Kind of Wrong: Why Learning to Fail can Teach us to Thrive. October 18, 2023 Edmondson A. Atria Books, New York, 2023. ISBN: 9781982195069. https://psnet.ahrq.gov/issue/right-kind-wrong-why-learning-fail-can-teach-us-thrive Despite the harm that failure can cause, its value as a learning opportunity, if exam…

1267. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45840/psn-pdf
      February 08, 2017 - Implementation of the safety huddle. February 8, 2017 Kylor C, Napier T, Rephann A, et al. Implementation of the Safety Huddle. Crit Care Nurse. 2016;36(6):80- 82. https://psnet.ahrq.gov/issue/implementation-safety-huddle The safety huddle is becoming common within health care practice as a way to inform clinician…

1268. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37024/psn-pdf
      January 02, 2017 - Every error a treasure: improving medication use with a nonpunitive reporting system. January 2, 2017 Lehmann DF, Page N, Kirschman K, et al. Every Error a Treasure: Improving Medication Use with a Nonpunitive Reporting System. Jt Comm J Qual Patient Saf. 2016;33(7):401-407. doi:10.1016/s1553- 7250(07)33046-8. ht…

1269. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43739/psn-pdf
      December 03, 2014 - Joshua’s Story. December 3, 2014 Anderson-Wallace M, Denning R. Leeds, UK: Patient Stories; October 18, 2014. https://psnet.ahrq.gov/issue/joshuas-story Patient stories are a growing component of understanding the impact of medical errors on patients and uncovering underlying causes. This video features an in-dept…

1270. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74846/psn-pdf
      February 16, 2022 - Weight-based Medication Errors in Children. February 16, 2022 Farnborough, UK: Healthcare Safety Investigation Branch; February 2022. https://psnet.ahrq.gov/issue/weight-based-medication-errors-children Weight-calculation errors can result in pediatric patient harm as they affect medication prescribing, dispensing…

1271. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73498/psn-pdf
      July 14, 2021 - Leaving a discontinued FentaNYL infusion attached to the patient leads to a tragic error July 14, 2021 ISMP Medication Safety Alert! Acute care edition. 2021;26(13);1-2. https://psnet.ahrq.gov/issue/leaving-discontinued-fentanyl-infusion-attached-patient-leads-tragic-error High-alert medication misadministration i…

1272. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/851924/psn-pdf
      August 02, 2023 - The things we carry: the scope and impact of second victim syndrome. August 2, 2023 Nosanov L, Elseth AJ, Maxwell J, et al. The things we carry: the scope and impact of second victim syndrome. Am J Surg. 2023;226(5):726-728. doi:10.1016/j.amjsurg.2023.06.035. https://psnet.ahrq.gov/issue/things-we-carry-scope-and-…

1273. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44917/psn-pdf
      November 30, 2016 - Canadian Incident Analysis Framework. November 30, 2016 Incident Analysis Collaborating Parties. Edmonton, AB: Canadian Patient Safety Institute; 2012. ISBN: 9781926541440. https://psnet.ahrq.gov/issue/canadian-incident-analysis-framework Performing incident analysis can help organizations understand why adverse e…

1274. 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

1275. 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…

1276. 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…

1277. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44108/psn-pdf
      November 06, 2015 - Service members are left in dark on health errors. November 6, 2015 LaFraniere S. New York Times. April 19, 2015. https://psnet.ahrq.gov/issue/service-members-are-left-dark-health-errors Reporting on a case involving an overlooked test result that contributed to the death of a patient in the military medical syste…

1278. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34773/psn-pdf
      March 08, 2017 - Medication Errors: The Nursing Experience. March 8, 2017 Wolf ZR. Albany NY: Delmar Publishers; 1994. ISBN: 9780827362628. https://psnet.ahrq.gov/issue/medication-errors-nursing-experience In one of the first professional books to deal with medication error from the nursing perspective, Wolf provides a comprehensi…

1279. 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

1280. 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…