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Showing results for "happen".

141. 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.

142. 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…

143. 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…

144. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866622/psn-pdf
     August 28, 2024 - Safety-I uses a traditional, reactive, and failure-focused approach to managing safety events when they happen … The assumption here is that the system is not complex, is inherently safe, and that bad things only happen … We should not ignore those instances when they happen, but we should also really be mindful that the

145. 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 …

146. Identifying Adverse Events Not Present on Admission: Can We Do It? | PSNet
     psnet.ahrq.gov/perspective/identifying-adverse-events-not-present-admission-can-we-do-it
     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

147. Drug error at Eskenazi Hospital killed prominent cancer researcher. Here's how it happened. | PSNet
     psnet.ahrq.gov/issue/drug-error-eskenazi-hospital-killed-prominent-cancer-researcher-heres-how-it-happened
     September 09, 2015 - Newspaper/Magazine Article Drug error at Eskenazi Hospital killed prominent cancer researcher. Here's how it happened. Citation Text: Drug error at Eskenazi Hospital killed prominent cancer researcher. Here's how it happened. Evans T. Indianapolis Star. October 30, 2020. Copy Citatio…

148. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47375/psn-pdf
     November 02, 2018 - ethical-duty-health-care-systems-address-interfacility-medical-error-discovery https://psnet.ahrq.gov/issue/could-it-happen-here-learning-other-organizations-safety-errors

149. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47061/psn-pdf
     July 25, 2018 - measuring-preventable-harm-helping-science-keep-pace-policy https://psnet.ahrq.gov/issue/adverse-outcomes-why-bad-things-happen-good-people

150. What happened to my patient? An educational intervention to facilitate postdischarge patient follow-up. | PSNet
     psnet.ahrq.gov/issue/what-happened-my-patient-educational-intervention-facilitate-postdischarge-patient-follow
     June 22, 2022 - Commentary What happened to my patient? An educational intervention to facilitate postdischarge patient follow-up. Citation Text: Narayana S, Rajkomar A, Harrison JD, et al. What Happened to My Patient? An Educational Intervention to Facilitate Postdischarge Patient Follow-Up. J Grad Med…

151. Cybersecurity for the Clinician. | PSNet
     psnet.ahrq.gov/issue/cybersecurity-clinician
     March 15, 2023 - This eight-episode video series provides an overview for non-technologists on how cyberattacks happen

152. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33820/psn-pdf
     December 01, 2016 - 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.

153. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866848/psn-pdf
     September 25, 2024 - We can make sure these processes happen the right way every time. … You cannot force that care pathway to happen a certain way every time. … And you do not know what is going to happen. … kind of thing where you can say, “Zero things will go wrong,” because I don't know how it's going to happen

154. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33867/psn-pdf
     October 01, 2018 - 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?" … and many vendors are making it available now for the first time, called CancelRx, but that doesn't happen

155. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34691/psn-pdf
     May 18, 2016 - human errors will occur and that are designed to minimize their occurrence and absorb them when they happen

156. Doctors make mistakes. A new documentary explores what happens when they do—and how to fix it. | PSNet
     psnet.ahrq.gov/issue/doctors-make-mistakes-new-documentary-explores-what-happens-when-they-do-and-how-fix-it
     November 20, 2019 - Newspaper/Magazine Article Doctors make mistakes. A new documentary explores what happens when they do—and how to fix it. Citation Text: Doctors make mistakes. A new documentary explores what happens when they do—and how to fix it. Park A. Time Magazine. January 24, 2019. Copy Citation…

157. Doctors must stop tuning out Black women. It happened to me, as a pregnant OB-GYN. | PSNet
     psnet.ahrq.gov/issue/doctors-must-stop-tuning-out-black-women-it-happened-me-pregnant-ob-gyn
     June 24, 2020 - Newspaper/Magazine Article Doctors must stop tuning out Black women. It happened to me, as a pregnant OB-GYN. Citation Text: Doctors must stop tuning out Black women. It happened to me, as a pregnant OB-GYN. Gillispie-Bell V. USA Today. April 14, 2023. Copy Citation S…

158. 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…

159. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43779/psn-pdf
     May 28, 2015 - debriefing in the emergency department, this commentary outlines how to determine when a debrief should happen

160. In Conversation With… David Blumenthal, MD, MPP | PSNet
     psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp-0
     March 27, 2024 - I foresee that that's what's going to happen in the world of data. … folks who put in the original wells or created the infrastructure, who at some level don't want that to happen … the fabric of life, instead of fighting them people would turn to improving them—and that that would happen