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Total Results: 1,692 records

Showing results for "happen".

441. 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 …

442. 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

443. 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

444. 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

445. 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…

446. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33879/psn-pdf
     May 01, 2019 - In Conversation With… Jane Brice, MD, MPH May 1, 2019 In Conversation With… Jane Brice, MD, MPH. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-jane-brice-md-mph Editor's note: Dr. Brice is Professor and Chair of the Department of Emergency Medicine at the University of North Carolina. She…

447. 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: …

448. 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 …

449. 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: …

450. In Conversation With… Susan Haas, MD, MSc | PSNet
     psnet.ahrq.gov/perspective/conversation-susan-haas-md-msc
     March 01, 2019 - And how can we make sure this doesn't happen again? … And that often doesn't happen, or it happens in a flurry of white coats being led around without getting

451. 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. …

452. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33639/psn-pdf
     September 01, 2006 - Well, I always say that the person who thinks it can never happen to them is the most dangerous person … space flight, and nuclear power, everybody knows that given the right set of circumstances it could happen

453. In Conversation With… Tejal K. Gandhi, MD, MPH | PSNet
     psnet.ahrq.gov/perspective/conversation-tejal-k-gandhi-md-mph
     February 26, 2025 - What needs to happen now is to say that it doesn't matter where you go, there's always going to be immediate

454. A multi-site assessment of inpatient safety event rates during the coronavirus disease 2019 pandemic. | PSNet
     psnet.ahrq.gov/issue/multi-site-assessment-inpatient-safety-event-rates-during-coronavirus-disease-2019-pandemic
     May 25, 2022 - Commentary A multi-site assessment of inpatient safety event rates during the coronavirus disease 2019 pandemic. Citation Text: Pollock BD, Dykhoff HJ, Breeher LE, et al. A multi-site assessment of inpatient safety event rates during the coronavirus disease 2019 pandemic. Mayo Clin Proc …

455. Clinical data sharing improves quality measurement and patient safety. | PSNet
     psnet.ahrq.gov/issue/clinical-data-sharing-improves-quality-measurement-and-patient-safety
     April 21, 2021 - Study Clinical data sharing improves quality measurement and patient safety. Citation Text: D’Amore JD, McCrary LK, Denson J, et al. Clinical data sharing improves quality measurement and patient safety. J Am Med Inform Assoc. 2021;28(7):1534-1542. doi:10.1093/jamia/ocab039. Copy Citat…

456. What safety events are reported for ambulatory care? Analysis of incident reports from a patient safety organization. | PSNet
     psnet.ahrq.gov/issue/what-safety-events-are-reported-ambulatory-care-analysis-incident-reports-patient-safety
     November 24, 2021 - Study What safety events are reported for ambulatory care? Analysis of incident reports from a patient safety organization. Citation Text: Sharma AE, Yang J, Del Rosario JB, et al. What safety events are reported for ambulatory care? Analysis of incident reports from a patient safety org…

457. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33794/psn-pdf
     November 01, 2015 - frustrating and exciting and enlightening because it's a really new way to think about how to make safety happen

458. Accreditation and Regulation: Can They Help Improve Patient Safety? | PSNet
     psnet.ahrq.gov/perspective/accreditation-and-regulation-can-they-help-improve-patient-safety
     April 01, 2009 - That is likely to happen through a combination of other policy tools, such as pay-for-performance and … 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

459. CLER Report of Findings 2021: Subprotocol for Operative and Procedural Areas. | PSNet
     psnet.ahrq.gov/issue/cler-report-findings-2021-subprotocol-operative-and-procedural-areas
     October 18, 2017 - September 1, 2021 Surgical errors happen, but are learners trained to recover from them

460. US and Canadian physicians' attitudes and experiences regarding disclosing errors to patients. | PSNet
     psnet.ahrq.gov/issue/us-and-canadian-physicians-attitudes-and-experiences-regarding-disclosing-errors-patients
     January 23, 2008 - Dealing with medical errors when they happen--instead of in court--can benefit doctors and patients,