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Total Results: 1,692 records

Showing results for "happen".

441. Targeting zero harm: a stretch goal that risks breaking the spring. | PSNet
     psnet.ahrq.gov/issue/targeting-zero-harm-stretch-goal-risks-breaking-spring
     December 01, 2021 - Commentary Targeting zero harm: a stretch goal that risks breaking the spring. Citation Text: Meddings J, Saint S, Lilford RJ, et al. Targeting zero harm: a stretch goal that risks breaking the spring. NEJM Catal Innov Care Deliv. 2020;1(4). doi:10.1056/cat.20.0354. Copy Citation F…

442. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33754/psn-pdf
     September 01, 2013 - To say these are humans, things happen in our systems that are so complex, resource constrained, and … will the hospital do to learn from this thing and make structural arrangements so that it may not happen

443. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73145/psn-pdf
     April 28, 2021 - KH: Do you think it might be overwhelming for patients when they think about all that could happen during

444. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33708/psn-pdf
     March 01, 2011 - of that, and that verbal communication could take place ideally in person, but obviously that can't happen … all the time, so at times it would happen over the phone. … is to focus it on two things: (1) the tasks to be done and (2) the anticipatory guidance, what may happen

445. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33750/psn-pdf
     May 01, 2013 - I'm interested in the millions of interactions that happen every day; the real innovation comes from … RW: It sounds like you think that will only happen if the incentives will drive the organizations to

446. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33752/psn-pdf
     August 01, 2013 - Mark out of the situation and replace him with some other person, are you going to see this problem happen … That actually didn't happen.

447. In Conversation with...Mark Chassin, MD, MPP, MPH | PSNet
     psnet.ahrq.gov/perspective/conversation-withmark-chassin-md-mpp-mph
     April 01, 2009 - different from routine process breakdowns because they represent unique sequences of errors that will never happen … into improvement, but when public stakeholders say that adverse events keep happening that should not happen … We have seen this happen with CPOE implementation and other kinds of IT implementation. … If you do not get the process working right before you automate it, bad things can happen to patients … That is likely to happen through a combination of other policy tools, such as pay-for-performance and

448. Incident Reporting: More Attention to the Safety Action Feedback Loop, Please | PSNet
     psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please
     September 01, 2011 - Incident Reporting: More Attention to the Safety Action Feedback Loop, Please Teryl K. Nuckols, MD, MSHS | September 1, 2011  Also Read a Conversation View more articles from the same authors. Citation Text: Nuckols TK. Incident Reporting: More Attention to the …

449. In Conversation With…Kaveh G. Shojania, MD | PSNet
     psnet.ahrq.gov/perspective/conversation-withkaveh-g-shojania-md
     September 01, 2011 - In Conversation With…Kaveh G. Shojania, MD September 1, 2011  Also Read an Essay Citation Text: In Conversation With…Kaveh G. Shojania, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 20…

450. In Conversation With… Matthew Weinger, MD | PSNet
     psnet.ahrq.gov/perspective/conversation-matthew-weinger-md
     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

451. Our Maturing Understanding of Safety Culture: How to Change It and How It Changes Safety | PSNet
     psnet.ahrq.gov/perspective/our-maturing-understanding-safety-culture-how-change-it-and-how-it-changes-safety
     March 01, 2017 - The evolutionary model of culture implies that culture change doesn't happen through one big fix, but … Errors can happen, but probably a million drug errors are made today. … That will happen when we can say we've optimized the technical intervention, we've optimized the implementation

452. Errors in otolaryngology revisited. | PSNet
     psnet.ahrq.gov/issue/errors-otolaryngology-revisited
     August 11, 2010 - Study Errors in otolaryngology revisited. Citation Text: Shah RK, Boss EF, Brereton J, et al. Errors in otolaryngology revisited. Otolaryngol Head Neck Surg. 2014;150(5):779-784. doi:10.1177/0194599814521985. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3…

453. The Child Health PSO at 10 years: an emerging learning network. | PSNet
     psnet.ahrq.gov/issue/child-health-pso-10-years-emerging-learning-network
     July 28, 2021 - Commentary The Child Health PSO at 10 years: an emerging learning network. Citation Text: Levy FH, Conrad KA, Kemper C, et al. The Child Health PSO at 10 Years: an emerging learning network. Pediatr Qual Saf. 2021;6(4):e449. doi:10.1097/pq9.0000000000000449. Copy Citation Format: …

454. Using name overlap analysis to understand medication name search safety. | PSNet
     psnet.ahrq.gov/issue/using-name-overlap-analysis-understand-medication-name-search-safety
     August 31, 2022 - Study Using name overlap analysis to understand medication name search safety. Citation Text: Flynn AJ, Mieure KD, Myers C. Using name overlap analysis to understand medication name search safety. Am J Health Syst Pharm. 2024;81(14):622-633. doi:10.1093/ajhp/zxae048. Copy Citation …

455. An examination of Leapfrog safety measures and Magnet designation. | PSNet
     psnet.ahrq.gov/issue/examination-leapfrog-safety-measures-and-magnet-designation
     January 27, 2021 - Study An examination of Leapfrog safety measures and Magnet designation. Citation Text: Tai TWC, Mattie A, Miller SM, et al. An examination of Leapfrog safety measures and Magnet designation. J Healthc Risk Manag. 2023;42(3-4):21-29. doi:10.1002/jhrm.21533. Copy Citation Format: …

456. Operating at night does not increase the risk of intraoperative adverse events. | PSNet
     psnet.ahrq.gov/issue/operating-night-does-not-increase-risk-intraoperative-adverse-events
     July 01, 2017 - Study Operating at night does not increase the risk of intraoperative adverse events. Citation Text: Eskesen TG, Peponis T, Saillant N, et al. Operating at night does not increase the risk of intraoperative adverse events. Am J Surg. 2018;216(1):19-24. doi:10.1016/j.amjsurg.2017.10.026. …

457. Multidisciplinary simulation activity effectively prepares residents for participation in patient safety activities. | PSNet
     psnet.ahrq.gov/issue/multidisciplinary-simulation-activity-effectively-prepares-residents-participation-patient
     November 30, 2016 - April 29, 2018 Surgical errors happen, but are learners trained to recover from them?

458. Effect of outcome on physician judgments of appropriateness of care. | PSNet
     psnet.ahrq.gov/issue/effect-outcome-physician-judgments-appropriateness-care
     June 23, 2015 - March 15, 2017 Ethics in the pediatric emergency department: when mistakes happen: an

459. Addressing ambulatory safety and malpractice: the Massachusetts PROMISES project. | PSNet
     psnet.ahrq.gov/issue/addressing-ambulatory-safety-and-malpractice-massachusetts-promises-project
     August 14, 2017 - It could happen to you.

460. Choosing your words carefully: how physicians would disclose harmful medical errors to patients. | PSNet
     psnet.ahrq.gov/issue/choosing-your-words-carefully-how-physicians-would-disclose-harmful-medical-errors-patients
     February 16, 2011 - Dealing with medical errors when they happen--instead of in court--can benefit doctors and patients,