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psnet.ahrq.gov/node/33857/psn-pdf
July 01, 2012 - I foresee that that's what's going to happen in the world of data. … 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
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psnet.ahrq.gov/issue/families-are-struggling-use-medicines-home-we-must-truly-involve-them-their-own-safety
February 02, 2022 - challenge to track medical errors that take place in the home environment , yet it is understood they happen
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psnet.ahrq.gov/issue/becoming-high-reliability-organization-through-shared-learning-safety-events
February 12, 2020 - reliability organizations consistently examine what goes wrong and remain aware that failure can happen
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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…
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psnet.ahrq.gov/perspective/conversation-charles-ornstein
October 01, 2009 - As you start reading through these forms, you start seeing the range of things that happen in health … out, but generally the institution did not make an effort to cover it up or to try to say it didn't happen … Part of the job of the media is not only to explain when these events happen but to try to put them in … So I think it's an excuse to try to say that it's just the media attention, that these problems happen … Is the goal to make it better or at some point do you just say this is not going to happen?
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psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety
October 01, 2009 - As you start reading through these forms, you start seeing the range of things that happen in health … out, but generally the institution did not make an effort to cover it up or to try to say it didn't happen … Part of the job of the media is not only to explain when these events happen but to try to put them in … So I think it's an excuse to try to say that it's just the media attention, that these problems happen … Is the goal to make it better or at some point do you just say this is not going to happen?
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psnet.ahrq.gov/node/49624/psn-pdf
May 01, 2011 - Angry and upset, the parents asked repeatedly, "How could this happen? … another health care worker's error can help
ensure that these challenging but important conversations happen
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psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-ii-duke-experience
July 20, 2010 - How could such a terrible mistake happen to a team of highly qualified and dedicated individuals in an … journey; the transition to an optimal culture of shared responsibility and accountability does not happen … have maintained the status quo, based on the mistaken premise that "mistakes like that could never happen
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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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psnet.ahrq.gov/issue/ed-revamp-team-approach-care-reduces-errors-boosts-patient-and-clinician-satisfaction
June 14, 2023 - March 17, 2021
Hospitals look to computers to predict patient emergencies before they happen
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psnet.ahrq.gov/issue/non-english-speakers-find-ers-hard-reach
January 18, 2023 - April 26, 2023
Hospitals look to computers to predict patient emergencies before they happen
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psnet.ahrq.gov/perspective/conversation-withsorrel-king
March 01, 2007 - lawyer at Hopkins, and said, "What happened to Josie, that little strike of lightning, that doesn't happen … These systems are eventually going to break down and something is going to happen that wasn't that doctor's … But something bad is going to happen and it's going to look like it's that person's fault or that person
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psnet.ahrq.gov/node/41280/psn-pdf
December 31, 2014 - information, and forecast the implications of this information (i.e., adverse consequences that might
happen
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psnet.ahrq.gov/node/42900/psn-pdf
September 19, 2016 - psychiatric units, but a prior Joint Commission sentinel event alert suggested that nearly 15% of
attempts happen
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psnet.ahrq.gov/issue/using-trainee-failures-enhance-learning-qualitative-study-pediatric-hospitalists-allowing
December 14, 2022 - allowing failure, the process of allowing or interrupting failure, and how they decide to allow failure to happen
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psnet.ahrq.gov/issue/delayed-admissions-pediatric-intensive-care-unit-progression-disease-or-errors-emergency
June 14, 2019 - Transitions of care happen multiple times in a patient’s hospital stay and are common times for preventable
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psnet.ahrq.gov/issue/debriefing-emergency-department-after-clinical-events-practical-guide
November 16, 2022 - debriefing in the emergency department, this commentary outlines how to determine when a debrief should happen
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psnet.ahrq.gov/perspective/conversation-withchristine-sinsky-md
February 26, 2025 - When computers entered your world, is it something you thought would happen or were you optimistic and … RW : It may not be obvious to everyone why that would happen since the imperatives to do the clerical … How can I make that happen?
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psnet.ahrq.gov/node/840174/psn-pdf
August 28, 2024 - for the liaison to set expectations for
surviving family members so they can prepare for what will happen … explanation is particularly important, as most families want to know that what happened to them
will not happen
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psnet.ahrq.gov/node/33716/psn-pdf
September 01, 2011 - In Conversation With…Kaveh G. Shojania, MD
September 1, 2011
In Conversation With…Kaveh G. Shojania, MD. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/conversation-withkaveh-g-shojania-md
Editor's note: Kaveh G. Shojania, MD, is the Canada Research Chair in Patient Safety and Quality
Improvement and t…