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Showing results for "happen".

1341. 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…

1342. 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

1343. What Do We Know About Emergency Department Safety? | PSNet
      psnet.ahrq.gov/perspective/what-do-we-know-about-emergency-department-safety
      June 01, 2010 - What about you and your background caused that to happen? … And you can watch them happen: You can just stand back sometimes and admire the cognitive choreography

1344. 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…

1345. 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…

1346. 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…

1347. 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…

1348. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50929/psn-pdf
      February 26, 2020 - They need to be aware of what may happen and when to reach out to their physician or go to the emergency

1349. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33722/psn-pdf
      December 01, 2011 - these high beds with a step stool beside it and that actually becomes like an accident waiting to happen

1350. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33712/psn-pdf
      June 01, 2011 - that there probably is someone thinking, "But what about this," or "Isn't this bad thing likely to happen

1351. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/860015/psn-pdf
      September 01, 2024 - generally considered to have experienced a “never event”, a safety event that is never supposed to happen

1352. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49512/psn-pdf
      May 01, 2006 - Performing an invasive procedure on the wrong patient should never happen.

1353. 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

1354. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2022-10/spotlight_case_missed_pneumothorax_10.09.2022_-_final.pdf
      January 01, 2022 - post- procedural pneumothorax with CXR, interpretation and communication of the CXR results did not happen

1355. The Wrong Channel | PSNet
      psnet.ahrq.gov/web-mm/wrong-channel
      February 01, 2003 - As we read about them (luckily, they never happen to us , of course), we are prompted to ask: Which

1356. Ventricular Wall Injury during a Diagnostic Cardiac Catheterization | PSNet
      psnet.ahrq.gov/web-mm/ventricular-wall-injury-during-diagnostic-cardiac-catheterization
      September 01, 2012 - Ultimately, this case is an excellent example of what can happen when best practices are not followed

1357. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33683/psn-pdf
      April 01, 2009 - That is likely to happen through a combination of other policy tools, such as pay-for-performance and

1358. Pocket Syringe Swap | PSNet
      psnet.ahrq.gov/web-mm/pocket-syringe-swap
      July 01, 2006 - They happen to almost every anesthesiologist sooner or later.

1359. Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules | PSNet
      psnet.ahrq.gov/web-mm/unintentional-ketamine-overdose-operating-room-mixing-ampules
      March 25, 2020 - Similar adverse drug events related to different drug concentrations in same-size ampules also happen

1360. 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…