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Showing results for "happen".

41. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/848382/psn-pdf
    May 03, 2023 - Events that inspired change: the importance of sharing what happened to stop it from happening again. May 3, 2023 Myers E, Allen C. Events that inspired change: the importance of sharing what happened to stop it from happening again. Patient Saf. 2023;5(1):62-63. doi:10.33940/001c.74079. https://psnet.ahrq.gov/iss…

42. Fatal mistakes: why do ten-fold medication errors in children keep happening? | PSNet
    psnet.ahrq.gov/issue/fatal-mistakes-why-do-ten-fold-medication-errors-children-keep-happening
    April 21, 2021 - View More Related Resources Prescribing errors in children: why they happen

43. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/851870/psn-pdf
    July 31, 2023 - that is a known risk of wheelchair usage, it is not one that staff may often think about or expect to happen … When we reviewed the event, we noted there is a warning on the package insert that a reaction could happen … It does not happen often, and most people don’t make that association. … What actions are you taking as an organization to make sure that this does not happen again? … still be viewed as airing dirty laundry, instead of sharing adverse events so similar events do not happen

44. Sorry Works! | PSNet
    psnet.ahrq.gov/issue/sorry-works
    November 15, 2024 - They encourage doctors and their insurers to be honest when mistakes happen, offer apologies, and provide

45. Teaching medical error apologies: development of a multi-component intervention. | PSNet
    psnet.ahrq.gov/issue/teaching-medical-error-apologies-development-multi-component-intervention
    August 04, 2021 - October 19, 2022 Surgical safety does not happen by accident: learning from perioperative … July 26, 2023 View More Related Resources Bad things can happen

46. Latent Error (or Latent Condition) | PSNet
    psnet.ahrq.gov/taxonomy/term/3488
    December 12, 2020 - Thus, latent errors are quite literally "accidents waiting to happen."

47. “I had no idea this happened”: electronic feedback on clinical reasoning for hospitalists. | PSNet
    psnet.ahrq.gov/issue/i-had-no-idea-happened-electronic-feedback-clinical-reasoning-hospitalists
    February 28, 2024 - Study “I had no idea this happened”: electronic feedback on clinical reasoning for hospitalists. Citation Text: Kotwal S, Udayappan KM, Kutheala N, et al. “I had no idea this happened”: electronic feedback on clinical reasoning for hospitalists. J Gen Intern Med. 2024;39(16):3271-3277. d…

48. A Call to Action: Dedicated Medication Safety Transformation in the Perioperative Setting. | PSNet
    psnet.ahrq.gov/issue/call-action-dedicated-medication-safety-transformation-perioperative-setting
    December 08, 2021 - Medication errors happen across the continuum of surgical care.

49. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/46626/psn-pdf
    December 22, 2018 - What happened to my patient? An educational intervention to facilitate postdischarge patient follow-up. December 22, 2018 Narayana S, Rajkomar A, Harrison JD, et al. What Happened to My Patient? An Educational Intervention to Facilitate Postdischarge Patient Follow-Up. J Grad Med Educ. 2017;9(5):627-633. doi:10.430…

50. A national mixed-methods evaluation of preparedness for general surgery residency and the association with resident burnout. | PSNet
    psnet.ahrq.gov/issue/national-mixed-methods-evaluation-preparedness-general-surgery-residency-and-association
    September 02, 2020 - September 9, 2020 When bad things happen: training medical students to anticipate the … September 2, 2020 Surgical errors happen, but are learners trained to recover from them

51. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/33674/psn-pdf
    February 01, 2009 - If you are going to promulgate a policy that either publicly reports adverse events that happen in hospitals … to be sure that the hospital is not being blamed, for lack of a better word, for things that didn't happen … Sometimes patients are sent to us because they've had bad things happen—they're very ill and it's our … That in fact, hospitals should be paying for things that shouldn't happen, and that this type of policy … system where we will pay for a given diagnosis, I think it is inevitable that when adverse events happen

52. In Conversation with...Diane Rydrych, MA | PSNet
    psnet.ahrq.gov/perspective/conversation-withdiane-rydrych-ma
    February 26, 2025 - RW: When you send out a safety alert, would it be because you've seen this thing happen once or because … know that they're very earnest in identifying reportable events and wanting to understand why they happen … across states would also be a real leap forward in terms of what we could learn about why these events happen … One thing that we've learned is that there are a lot of reasons why these events happen and why they

53. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/73542/psn-pdf
    July 28, 2021 - psnet.ahrq.gov/issue/diagnostic-safety-event-reporting Adverse event reporting can clarify when mistakes happen

54. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/867529/psn-pdf
    January 15, 2025 - “I had no idea this happened”: electronic feedback on clinical reasoning for hospitalists. January 15, 2025 Kotwal S, Udayappan KM, Kutheala N, et al. “I had no idea this happened”: electronic feedback on clinical reasoning for hospitalists. J Gen Intern Med. 2024;39(16):3271-3277. doi:10.1007/s11606-024-09058-1. …

55. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/45664/psn-pdf
    July 02, 2017 - Intraoperative adverse events in abdominal surgery: what happens in the operating room does not stay in the operating room. July 2, 2017 Bohnen JD, Mavros MN, Ramly EP, et al. Intraoperative Adverse Events in Abdominal Surgery: What Happens in the Operating Room Does Not Stay in the Operating Room. Ann Surg. 2017;…

56. Safety culture and the positive association of being a primary care training practice during COVID-19: the results of the multi-country European PRICOV-19 Study. | PSNet
    psnet.ahrq.gov/issue/safety-culture-and-positive-association-being-primary-care-training-practice-during-covid-19
    January 08, 2025 - Improving Diagnostic Safety and Quality April 26, 2023 Bad things can happen … September 30, 2020 When bad things happen: training medical students to anticipate the

57. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/61127/psn-pdf
    November 11, 2020 - Drug error at Eskenazi Hospital killed prominent cancer researcher. Here's how it happened. November 11, 2020 Evans T. Indianapolis Star. October 30, 2020. https://psnet.ahrq.gov/issue/drug-error-eskenazi-hospital-killed-prominent-cancer-researcher-heres-how-it- happened Fentanyl is a high-alert medication that c…

58. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/838180/psn-pdf
    January 01, 2023 - To err is human, but what happens when surgeons err? September 28, 2022 Lin JS, Olutoye OO, Samora JB. To err is human, but what happens when surgeons err? J Pediatr Surg. 2023;58(3):496-502. doi:10.1016/j.jpedsurg.2022.06.019. https://psnet.ahrq.gov/issue/err-human-what-happens-when-surgeons-err Clinicians involv…

59. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/42567/psn-pdf
    September 11, 2013 - What happens to the medication regimens of older adults during and after an acute hospitalization? September 11, 2013 Harris CM, Sridharan A, Landis R, et al. What happens to the medication regimens of older adults during and after an acute hospitalization? J Patient Saf. 2013;9(3):150-3. doi:10.1097/PTS.0b013e3182…

60. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/854642/psn-pdf
    October 18, 2023 - This eight-episode video series provides an overview for non-technologists on how cyberattacks happen