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Showing results for "happen".

61. 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

62. 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. …

63. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/73331/psn-pdf
    May 26, 2021 - issue/cancer-diagnoses-delayed-among-prisoners-washington-state https://psnet.ahrq.gov/issue/could-it-happen-here-learning-other-organizations-safety-errors

64. 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;…

65. 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…

66. Inside the preventable deaths that happened within a prominent transplant center. | PSNet
    psnet.ahrq.gov/issue/inside-preventable-deaths-happened-within-prominent-transplant-center
    May 02, 2018 - Newspaper/Magazine Article Inside the preventable deaths that happened within a prominent transplant center. Citation Text: Inside the preventable deaths that happened within a prominent transplant center. Blau M. ProPublica. June 14, 2023. Copy Citation Save S…

67. 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…

68. 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…

69. 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…

70. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/33648/psn-pdf
    March 01, 2007 - lawyer at Hopkins, and said, "What happened to Josie, that little strike of lightning, that doesn't happen … These systems are eventually going to break down and something is going to happen that wasn't that doctor's … But something bad is going to happen and it's going to look like it's that person's fault or that person

71. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/867190/psn-pdf
    November 20, 2024 - This article introduces why diagnostic errors happen, commonly misdiagnosed conditions, and strategies

72. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/844554/psn-pdf
    February 15, 2023 - Medication mix-up: what happened at Vanderbilt and how it impacts health care providers. February 15, 2023 Michel C, Talley C. J Health Life Sci Law. 2022;17(1):71 https://psnet.ahrq.gov/issue/medication-mix-what-happened-vanderbilt-and-how-it-impacts-health-care- providers High-profile medication errors like tha…

73. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/867653/psn-pdf
    February 26, 2025 - “Why did it happen?” “What are we doing to keep it from happening again?”

74. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/40194/psn-pdf
    June 20, 2011 - What happens when things go wrong? June 20, 2011 Brandom BW, Callahan P, Micalizzi DA. What happens when things go wrong? Paediatr Anaesth. 2011;21(7):730-6. doi:10.1111/j.1460-9592.2010.03513.x. https://psnet.ahrq.gov/issue/what-happens-when-things-go-wrong This commentary reveals a personal story of loss and dis…

75. In Conversation with... Regina Hoffman about Building Capacity for Patient Safety | PSNet
    psnet.ahrq.gov/perspective/conversation-regina-hoffman-about-building-capacity-patient-safety
    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

76. Building Capacity for Patient Safety | PSNet
    psnet.ahrq.gov/perspective/building-capacity-patient-safety
    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

77. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/33651/psn-pdf
    June 01, 2007 - 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

78. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/74276/psn-pdf
    January 19, 2022 - guideline-prevention-unintentionally-retained-surgical-items Retained surgical items (RSI) are a never event, yet they continue to happen

79. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/50827/psn-pdf
    January 22, 2020 - High reliability organizations consistently examine what goes wrong and remain aware that failure can happen

80. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/867085/psn-pdf
    November 06, 2024 - A WebM&M highlights errors that can happen when medication kits are not standardized and are poorly