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Showing results for "happen".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/860386/psn-pdf
    January 10, 2024 - Conceptualising learning from resilient performance: a scoping literature review. January 10, 2024 Degerman H, Wallo A. Conceptualising learning from resilient performance: a scoping literature review. Appl Ergon. 2024;115:104165. doi:10.1016/j.apergo.2023.104165. https://psnet.ahrq.gov/issue/conceptualising-learn…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37024/psn-pdf
    January 02, 2017 - Every error a treasure: improving medication use with a nonpunitive reporting system. January 2, 2017 Lehmann DF, Page N, Kirschman K, et al. Every Error a Treasure: Improving Medication Use with a Nonpunitive Reporting System. Jt Comm J Qual Patient Saf. 2016;33(7):401-407. doi:10.1016/s1553- 7250(07)33046-8. ht…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43739/psn-pdf
    December 03, 2014 - Joshua’s Story. December 3, 2014 Anderson-Wallace M, Denning R. Leeds, UK: Patient Stories; October 18, 2014. https://psnet.ahrq.gov/issue/joshuas-story Patient stories are a growing component of understanding the impact of medical errors on patients and uncovering underlying causes. This video features an in-dept…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45840/psn-pdf
    February 08, 2017 - Implementation of the safety huddle. February 8, 2017 Kylor C, Napier T, Rephann A, et al. Implementation of the Safety Huddle. Crit Care Nurse. 2016;36(6):80- 82. https://psnet.ahrq.gov/issue/implementation-safety-huddle The safety huddle is becoming common within health care practice as a way to inform clinician…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74846/psn-pdf
    February 16, 2022 - Weight-based Medication Errors in Children. February 16, 2022 Farnborough, UK: Healthcare Safety Investigation Branch; February 2022. https://psnet.ahrq.gov/issue/weight-based-medication-errors-children Weight-calculation errors can result in pediatric patient harm as they affect medication prescribing, dispensing…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73498/psn-pdf
    July 14, 2021 - Leaving a discontinued FentaNYL infusion attached to the patient leads to a tragic error July 14, 2021 ISMP Medication Safety Alert! Acute care edition. 2021;26(13);1-2. https://psnet.ahrq.gov/issue/leaving-discontinued-fentanyl-infusion-attached-patient-leads-tragic-error High-alert medication misadministration i…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851924/psn-pdf
    August 02, 2023 - The things we carry: the scope and impact of second victim syndrome. August 2, 2023 Nosanov L, Elseth AJ, Maxwell J, et al. The things we carry: the scope and impact of second victim syndrome. Am J Surg. 2023;226(5):726-728. doi:10.1016/j.amjsurg.2023.06.035. https://psnet.ahrq.gov/issue/things-we-carry-scope-and-…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33881/psn-pdf
    August 01, 2019 - In Conversation With… Erik Hollnagel, PhD June 1, 2019 In Conversation With… Erik Hollnagel, PhD. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-erik-hollnagel-phd Editor's note: Dr. Hollnagel is Senior Professor of Patient Safety at the University of Jönköping (Sweden) as well as Visiting…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33704/psn-pdf
    December 01, 2010 - open and honest, I'd ask them if you could use it within the organization to help ensure this doesn't happen

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44917/psn-pdf
    November 30, 2016 - Canadian Incident Analysis Framework. November 30, 2016 Incident Analysis Collaborating Parties. Edmonton, AB: Canadian Patient Safety Institute; 2012. ISBN: 9781926541440. https://psnet.ahrq.gov/issue/canadian-incident-analysis-framework Performing incident analysis can help organizations understand why adverse e…

  11. The Wrong Shot: Error Disclosure | PSNet

    psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure
    May 01, 2011 - SPOTLIGHT CASE The Wrong Shot: Error Disclosure Citation Text: Gallagher TH, Levinson W. The Wrong Shot: Error Disclosure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Sch…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49450/psn-pdf
    June 01, 2004 - The Wrong Shot: Error Disclosure June 1, 2004 Gallagher TH, Levinson W. The Wrong Shot: Error Disclosure. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure Case Objectives Describe the rationale for disclosing harmful errors to patients. Describe the specific information that patie…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44108/psn-pdf
    November 06, 2015 - Service members are left in dark on health errors. November 6, 2015 LaFraniere S. New York Times. April 19, 2015. https://psnet.ahrq.gov/issue/service-members-are-left-dark-health-errors Reporting on a case involving an overlooked test result that contributed to the death of a patient in the military medical syste…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34773/psn-pdf
    March 08, 2017 - Medication Errors: The Nursing Experience. March 8, 2017 Wolf ZR. Albany NY: Delmar Publishers; 1994. ISBN: 9780827362628. https://psnet.ahrq.gov/issue/medication-errors-nursing-experience In one of the first professional books to deal with medication error from the nursing perspective, Wolf provides a comprehensi…

  15. In Conversation With… Robert Hirschtick, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-robert-hirschtick-md
    January 01, 2018 - We are testifying to things that didn't actually happen, physical exam findings that we didn't do, or

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33816/psn-pdf
    October 01, 2016 - ways illustrating that a patient is at risk for a bad thing happening or a bad thing is starting to happen

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/842779/psn-pdf
    January 12, 2011 - Resilience Engineering in Practice: a Guidebook. January 12, 2011 Hollnagel E, Parie?s J, Woods DD et al eds. Farnham UK; Ashgate, 2011. ISBN: 9781472420749 https://psnet.ahrq.gov/issue/resilience-engineering-practice-guidebook Safety-critical industries rely on organizational aptitude to respond to disr…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49425/psn-pdf
    November 01, 2003 - Misread Label November 1, 2003 Franklin BD. Misread Label. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/misread-label The Case An infant was born with sluggish respirations. During labor the infant’s mother had received meperidine [Demerol, a pain medication], a narcotic with a half-life of 2.5-4.0 hours…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47159/psn-pdf
    August 01, 2018 - Safety II behavior in a pediatric intensive care unit. August 1, 2018 Merandi J, Vannatta K, Davis T, et al. Safety II Behavior in a Pediatric Intensive Care Unit. Pediatrics. 2018;141(6):e20180018. doi:10.1542/peds.2018-0018. https://psnet.ahrq.gov/issue/safety-ii-behavior-pediatric-intensive-care-unit The tradit…

  20. EHR Copy and Paste and Patient Safety | PSNet

    psnet.ahrq.gov/perspective/ehr-copy-and-paste-and-patient-safety
    January 01, 2018 - We are testifying to things that didn't actually happen, physical exam findings that we didn't do, or
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