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psnet.ahrq.gov/issue/they-are-terrified-fearing-coronavirus-people-potentially-fatal-conditions-avoid-emergency
May 27, 2020 - March 25, 2020
Surgical errors happen, but are learners trained to recover from them?
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psnet.ahrq.gov/issue/partnering-families-and-patient-advocates-another-line-defense-adverse-event-surveillance
September 11, 2019 - July 24, 2019
Hospitals look to computers to predict patient emergencies before they happen
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psnet.ahrq.gov/issue/fewer-better-auditory-alarms-will-improve-patient-safety
August 11, 2021 - February 14, 2024
Surgical safety does not happen by accident: learning from perioperative
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psnet.ahrq.gov/issue/quality-improvement-universal-protocol-use-office-based-gastrointestinal-procedure-units
November 16, 2022 - January 2, 2017
Adverse outcomes: why bad things happen to good people.
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psnet.ahrq.gov/issue/cancer-drug-shortages-grow-some-doctors-are-forced-ration-doses-or-delay-care
April 26, 2023 - July 22, 2020
When mistakes happen.
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psnet.ahrq.gov/issue/increased-incidence-anesthetic-adverse-events-late-afternoon-surgeries
October 19, 2022 - February 7, 2024
Surgical safety does not happen by accident: learning from perioperative
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psnet.ahrq.gov/issue/no-bad-apples
May 15, 2019 - December 14, 2012
Program encourages reporting accidents waiting to happen: the Good
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psnet.ahrq.gov/issue/nearly-90-major-medical-mistakes-logged-utah-hospitals-2008
July 02, 2009 - September 27, 2016
Program encourages reporting accidents waiting to happen: the Good
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psnet.ahrq.gov/issue/administering-saline-flush-site-unseen-can-lead-wrong-route-error
June 10, 2018 - Related Resources From the Same Author(s)
Fatal PCA adverse events continue to happen
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psnet.ahrq.gov/issue/quality-improvement-series
July 05, 2013 - February 8, 2023
Bad things can happen: are medical students aware of patient centered
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psnet.ahrq.gov/issue/make-hospitals-less-deadly-dose-data
August 13, 2014 - Dealing with medical errors when they happen--instead of in court--can benefit doctors and patients,
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psnet.ahrq.gov/issue/hospital-takes-page-toyota
April 03, 2005 - June 17, 2014
Could it happen here?
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psnet.ahrq.gov/issue/smart-pumps-advanced-capabilities-and-continuous-quality-improvement
December 10, 2014 - Dealing with medical errors when they happen--instead of in court--can benefit doctors and patients,
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psnet.ahrq.gov/issue/two-steps-forward-and-one-step-back-patient-safety
June 10, 2018 - August 8, 2018
Fatal PCA adverse events continue to happen...better patient monitoring
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psnet.ahrq.gov/issue/making-hospitals-safe-people-diabetes
November 14, 2018 - 31, 2023
Hospitals look to computers to predict patient emergencies before they happen
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psnet.ahrq.gov/issue/retrospective-analysis-medication-incidents-reported-using-line-reporting-system
April 01, 2015 - Web-based reporting system to monitor types of medication errors and near misses , determine when they happen
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psnet.ahrq.gov/node/33654/psn-pdf
August 01, 2007 - the CEO of this institution and said, well, at least it's nice to know that
things like that don't happen … How did that happen?
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psnet.ahrq.gov/primer/safety-i-safety-ii-and-new-views-safety
October 02, 2024 - Hollnagel terms this the causality credo , which he defines as “the belief that adverse outcomes happen … “Work-as-imagined" describes what is expected to happen under anticipated normal working conditions, … Nonetheless, because these events are frequent, if we can understand how and why they happen, we can
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psnet.ahrq.gov/perspective/conversation-timothy-b-mcdonald-md-jd
February 26, 2025 - It has moved to include supporting physicians when mistakes happen but way beyond that.
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psnet.ahrq.gov/issue/fake-it-til-you-make-it-pressures-measure-surgical-training
October 25, 2023 - July 2, 2014
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Related Resources
Surgical errors happen