Results

Total Results: 1,692 records

Showing results for "happen".

201. Patient perspectives on adverse event investigations in health care. | PSNet
     psnet.ahrq.gov/issue/patient-perspectives-adverse-event-investigations-health-care
     December 18, 2024 - the investigation or not, communicating to the patient what was learned so that the error will not happen

202. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50392/psn-pdf
     September 01, 2019 - I remember Ken Kizer announcing these eight things that should never happen in health care and they … The notion that some things should not happen, that we should have a high degree of accuracy around, … "This should always happen"; "this should never happen."

203. In Conversation With…Christine A. Sinsky, MD | PSNet
     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?

204. Preventing medication errors during codes. | PSNet
     psnet.ahrq.gov/issue/preventing-medication-errors-during-codes
     February 22, 2023 - Related Resources Hospitals look to computers to predict patient emergencies before they happen

205. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/842919/psn-pdf
     February 01, 2023 - of basal and/or nutritional insulin in a patient with type 1 diabetes is an event that should never happen … Ask what will happen with your medicines. 3. Know what will happen with your diet. 4. … Find out what will happen when you go home.

206. 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…

207. Psn-Pdf (pdf file)
     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

208. In Conversation with...Steven J. Spear, DBA, MS, MS | PSNet
     psnet.ahrq.gov/perspective/conversation-withsteven-j-spear-dba-ms-ms
     August 01, 2009 - time at the right dose without asking the nurses to do endless workarounds to make sure that will all happen … Now without stopping the work, what could happen at that point is that the nurse does go procure the … RW: Does this not happen in health care because the nurse doesn't think about her work that way? … If you look at the financial market, what will happen is that for all the finger pointing that's going … Maybe the first measures are very simple: yes or no, did a never event happen?

209. Workarounds and Resiliency on the Front Lines of Health Care | PSNet
     psnet.ahrq.gov/perspective/workarounds-and-resiliency-front-lines-health-care
     August 01, 2009 - time at the right dose without asking the nurses to do endless workarounds to make sure that will all happen … Now without stopping the work, what could happen at that point is that the nurse does go procure the … RW: Does this not happen in health care because the nurse doesn't think about her work that way? … If you look at the financial market, what will happen is that for all the finger pointing that's going … Maybe the first measures are very simple: yes or no, did a never event happen?

210. Unexpected hypoglycemia in a critically ill patient. | PSNet
     psnet.ahrq.gov/issue/unexpected-hypoglycemia-critically-ill-patient
     July 25, 2018 - is presented to illustrate the importance of bridging what happens at the bedside with what needs to happen

211. Intraoperative adverse events in abdominal surgery: what happens in the operating room does not stay in the operating room. | PSNet
     psnet.ahrq.gov/issue/intraoperative-adverse-events-abdominal-surgery-what-happens-operating-room-does-not-stay
     January 23, 2017 - Study Intraoperative adverse events in abdominal surgery: what happens in the operating room does not stay in the operating room. Citation Text: Bohnen JD, Mavros MN, Ramly EP, et al. Intraoperative Adverse Events in Abdominal Surgery: What Happens in the Operating Room Does Not Stay in …

212. Missed CANDOR Implementation Opportunities. | PSNet
     psnet.ahrq.gov/web-mm/missed-candor-implementation-opportunities
     November 11, 2020 - 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

213. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33863/psn-pdf
     August 01, 2018 - You can imagine 1 week in 5 for circumstances that virtually never happen. … I imagine that some of it they're training over and over again for things that essentially never happen … someone is saying "push a drug," then there has to be someone behind the curtain showing what would happen

214. Duty to Disclose Someone Else's Error? | PSNet
     psnet.ahrq.gov/web-mm/duty-disclose-someone-elses-error
     June 01, 2004 - 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

215. Exploring clinical lessons learned by experienced hospitalists from diagnostic errors and successes. | PSNet
     psnet.ahrq.gov/issue/exploring-clinical-lessons-learned-experienced-hospitalists-diagnostic-errors-and-successes
     January 15, 2025 - Study Exploring clinical lessons learned by experienced hospitalists from diagnostic errors and successes. Citation Text: Kotwal S, Howell M, Zwaan L, et al. Exploring clinical lessons learned by experienced hospitalists from diagnostic errors and successes. J Gen Intern Med. 2024;39(8):…

216. Blame culture and defensive medicine. | PSNet
     psnet.ahrq.gov/issue/blame-culture-and-defensive-medicine
     January 20, 2021 - It could happen to you.

217. Curing our diagnostic disorder. | PSNet
     psnet.ahrq.gov/issue/curing-our-diagnostic-disorder
     December 04, 2019 - June 30, 2021 Hospitals look to computers to predict patient emergencies before they happen

218. Family of woman who died after a medical error joins hospital's safety panel. | PSNet
     psnet.ahrq.gov/issue/family-woman-who-died-after-medical-error-joins-hospitals-safety-panel
     May 13, 2020 - November 18, 2015 When mistakes happen.

219. In Conversation With… Shantanu Agrawal, MD, MPhil | PSNet
     psnet.ahrq.gov/perspective/conversation-shantanu-agrawal-md-mphil
     February 26, 2025 - I remember Ken Kizer announcing these eight things that should never happen in health care and they all … The notion that some things should not happen, that we should have a high degree of accuracy around, … "This should always happen"; "this should never happen."

220. 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…