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Total Results: 466 records

Showing results for "happen".

  1. Primary Care and Patient Safety: Opportunities at the Interface | PSNet

    psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
    September 28, 2022 - If we're not going to reimburse, it's just not going to happen. … this is what works, we will need to figure out the financial models, logistically how you make this happen … Suddenly, it was a conversation that could happen at the dinner table, at the bowling alley, or at the … There’s lots of ways to do this and many places where this can happen. For instance, medications.

  2. Communication Error in a Closed ICU | PSNet

    psnet.ahrq.gov/web-mm/communication-error-closed-icu
    July 01, 2016 - July 5, 2023 Prescribing errors in children: why they happen and how to prevent them.

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836839/psn-pdf
    March 31, 2022 - Annual Perspective: Psychological Safety of Healthcare Staff March 31, 2022 Kingston MB, Dowell P, Mossburg SE, et al. Annual Perspective: Psychological Safety of Healthcare Staff. PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/annual-perspective-psychological-safety-healthcare-staff Introduction The…

  4. Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia | PSNet

    psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubation-and-severe-hypoxemia
    January 29, 2021 - performed by frontline personnel, often in times of uncertainty and stress, to prevent errors before they happen

  5. Are We Pushing Graduate Nurses Too Fast? | PSNet

    psnet.ahrq.gov/web-mm/are-we-pushing-graduate-nurses-too-fast
    November 16, 2022 - comprehensive transition to practice program for nurses incorporate so that situations like this don't happen

  6. In Conversation With... Libby Hoy and Stephen Hoy | PSNet

    psnet.ahrq.gov/perspective/conversation-libby-hoy-and-stephen-hoy
    March 10, 2021 - Authentic engagement doesn't just happen—it has to be intentional, and it has to have infrastructure

  7. Cups of Error | PSNet

    psnet.ahrq.gov/web-mm/cups-error
    January 12, 2011 - medication cups represents an understandable and almost predictable event—a veritable accident waiting to happen

  8. Building a Safety Program Using Principles of Resilience Engineering | PSNet

    psnet.ahrq.gov/perspective/building-safety-program-using-principles-resilience-engineering
    October 23, 2013 - Making it happen—from research to practice. In: Hollnagel E, Braithwaite J, Wears RL, eds.

  9. Saved by ECMO | PSNet

    psnet.ahrq.gov/web-mm/saved-ecmo
    May 05, 2017 - was appropriate and was likely the safest option, the anesthesia team failed to plan for what would happen

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33567/psn-pdf
    June 15, 2024 - Handoffs June 15, 2024 Handoffs and Signouts. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/handoffs PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice in the patient safety field. Last reviewed in 2024. Backgroun…

  11. Discharge Fumbles | PSNet

    psnet.ahrq.gov/web-mm/discharge-fumbles
    September 09, 2009 - SPOTLIGHT CASE Discharge Fumbles Citation Text: Forster AJ. Discharge Fumbles. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…

  12. The Inside of a Time Out | PSNet

    psnet.ahrq.gov/web-mm/inside-time-out
    March 01, 2004 - The Inside of a Time Out Citation Text: Feldman DL. The Inside of a Time Out. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged …

  13. Prolonged DKA in Pregnancy: A Case of Communication Breakdown. | PSNet

    psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown
    June 28, 2023 - SPOTLIGHT CASE Prolonged DKA in Pregnancy: A Case of Communication Breakdown. Citation Text: Marshall S, Boe NM. Prolonged DKA in Pregnancy: A Case of Communication Breakdown.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services…

  14. In Conversation with…Barbara A. Blakeney, MS, RN | PSNet

    psnet.ahrq.gov/perspective/conversation-withbarbara-blakeney-ms-rn
    August 01, 2005 - RW: What can make these changes happen?

  15. Pre-analytical pitfalls: Missing and mislabeled specimens | PSNet

    psnet.ahrq.gov/web-mm/pre-analytical-pitfalls-missing-and-mislabeled-specimens
    April 18, 2018 - under-reported. 6-8 The busy nature of the ED environment increases the likelihood for mislabel events to happen

  16. Annual Perspective: Psychological Safety of Healthcare Staff | PSNet

    psnet.ahrq.gov/perspective/annual-perspective-psychological-safety-healthcare-staff
    November 16, 2022 - Annual Perspective Annual Perspective: Psychological Safety of Healthcare Staff March 31, 2022  View more articles from the same authors. Citation Text: Kingston MB, Dowell P, Mossburg SE, et al. Annual Perspective: Psychological Safety of Healthcare Staff. P…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33588/psn-pdf
    March 15, 2025 - Second Victims: Support for Clinicians Involved in Errors and Adverse Events March 15, 2025 Second Victims: Support for Clinicians Involved in Errors and Adverse Events. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events PSNet primers are regu…

  18. Disclosure of Errors | PSNet

    psnet.ahrq.gov/primer/disclosure-errors
    September 15, 2024 - Disclosure of Errors Citation Text: Disclosure of Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  19. Meaningful Measurement in Patient and Family Engagement | PSNet

    psnet.ahrq.gov/perspective/meaningful-measurement-patient-and-family-engagement
    March 10, 2021 - Authentic engagement doesn't just happen—it has to be intentional, and it has to have infrastructure

  20. In Conversation with David W. Bates about Are We Safer Today? | PSNet

    psnet.ahrq.gov/perspective/conversation-david-w-bates-about-are-we-safer-today
    February 26, 2025 - But that does not happen now at most institutions or even for the best checklists.
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