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Total Results: 1,790 records

Showing results for "happen".

  1. 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

  2. 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

  3. 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

  4. 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

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73302/psn-pdf
    May 26, 2021 - How do we shift the thinking to the idea that these are harms that may happen to the patient, be it … for bringing something forward that only makes the organization better, but unfortunately that does happen … Why did this error happen?

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33875/psn-pdf
    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

  7. In Conversation with... Ellen Deutsch, MD, MS, FACS, FAAP, FSSH, CPPS | PSNet

    psnet.ahrq.gov/perspective/conversation-ellen-deutsch-md-ms-facs-faap-fssh-cpps
    December 14, 2022 - It was always a draft because as the day evolved, things would happen that changed that plan. … All patient care events happen in the context of other people and other parts of the system. … It’s the idea that we think that work—like providing healthcare—will happen a certain way, but when work … actually happens, people often have to make adjustments to make the work happen effectively and get … All these situations happen while considering the conditions, capabilities, and preferences of individual

  8. Resilient Healthcare and the Safety-I and Safety-II Frameworks | PSNet

    psnet.ahrq.gov/perspective/resilient-healthcare-and-safety-i-and-safety-ii-frameworks
    December 14, 2022 - All these situations happen while considering the conditions, capabilities, and preferences of individual … It was always a draft because as the day evolved, things would happen that changed that plan. … All patient care events happen in the context of other people and other parts of the system. … It’s the idea that we think that work—like providing healthcare—will happen a certain way, but when work … actually happens, people often have to make adjustments to make the work happen effectively and get

  9. Patient Safety. | PSNet

    psnet.ahrq.gov/issue/patient-safety-10
    May 01, 2023 - May 1, 2023 Program encourages reporting accidents waiting to happen: the Good Catch

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47092/psn-pdf
    October 13, 2018 - still-hard-share-psos-making-progress-still-face-tech-hurdles https://psnet.ahrq.gov/issue/could-it-happen-here-learning-other-organizations-safety-errors

  11. 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.

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33628/psn-pdf
    February 01, 2006 - He "feels" himself and his world intensely, so that when an error comes along, two things happen: first … As I started learning about errors, how they happen, and how complex and multi-factorial they often … and, number two, "What's going to happen to me as a result of this?"

  13. Getting Ahead of Harm Before It Happens: A Guide About Proactive Analysis for Improving Surgical Care Safety. | PSNet

    psnet.ahrq.gov/issue/getting-ahead-harm-it-happens-guide-about-proactive-analysis-improving-surgical-care-safety
    November 30, 2016 - Book/Report Getting Ahead of Harm Before It Happens: A Guide About Proactive Analysis for Improving Surgical Care Safety. Citation Text: Getting Ahead of Harm Before It Happens: A Guide About Proactive Analysis for Improving Surgical Care Safety. Wiley K, Davies JM. Edmonton, AB: Canadia…

  14. Risk, society and system failure. | PSNet

    psnet.ahrq.gov/issue/risk-society-and-system-failure
    November 29, 2023 - The author discusses why large scale accidents happen and how to manage risk in radiology by adhering

  15. Removing Insult from Injury—Disclosing Adverse Events | PSNet

    psnet.ahrq.gov/perspective/removing-insult-injury-disclosing-adverse-events
    February 01, 2006 - He "feels" himself and his world intensely, so that when an error comes along, two things happen: first … As I started learning about errors, how they happen, and how complex and multi-factorial they often are … and, number two, "What's going to happen to me as a result of this?"

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39193/psn-pdf
    April 21, 2011 - psnet.ahrq.gov/issue/disclosing-harmful-mammography-errors-patients Disclosing errors to patients does not happen

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853240/psn-pdf
    September 06, 2023 - Videos of simulated after action reviews: a training resource to support social and inclusive learning from patient safety events. September 6, 2023 McCarthy SE, Hogan C, Jenkins L, et al. Videos of simulated after action reviews: a training resource to support social and inclusive learning from patient safety eve…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47861/psn-pdf
    April 24, 2019 - Laney's story: the problem of delayed diagnosis of pediatric stroke. April 24, 2019 Fitzsimons BT, Fitzsimons LL, Sun LR. Laney's Story: The Problem of Delayed Diagnosis of Pediatric Stroke. Pediatrics. 2019;143(4):e20183458. doi:10.1542/peds.2018-3458. https://psnet.ahrq.gov/issue/laneys-story-problem-delayed-dia…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47777/psn-pdf
    January 01, 2021 - care professionals can optimize the patient experience even when complications and safety events happen

  20. Patients should know who's operating, surgeons say. | PSNet

    psnet.ahrq.gov/issue/patients-should-know-whos-operating-surgeons-say
    May 15, 2024 - Status December 18, 2019 Program encourages reporting accidents waiting to happen
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