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Total Results: 1,692 records

Showing results for "happen".

781. 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

782. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/863766/psn-pdf
     March 06, 2024 - Legacy: a Black Physician Reckons with Racism in Medicine. March 6, 2024 Blackstock U. New York, NY: Viking; 2024. ISBN: 9780593491287. https://psnet.ahrq.gov/issue/legacy-black-physician-reckons-racism-medicine The history of systemic racism is emerging to motivate health care equity and safety efforts. This memo…

783. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35779/psn-pdf
     July 20, 2010 - Our story. July 20, 2010 King S. Our story. Pediatr Radiol. 2006;36(4):284-6. https://psnet.ahrq.gov/issue/our-story The author tells the story of medical errors that led to the death of her daughter Josie in 2001 and discusses the activities her family has undertaken to prevent similar incidents from happening to…

784. Use of an interactive, telephone-based self-management support program to identify adverse events among ambulatory diabetes patients. | PSNet
     psnet.ahrq.gov/issue/use-interactive-telephone-based-self-management-support-program-identify-adverse-events-among
     June 11, 2010 - Study Use of an interactive, telephone-based self-management support program to identify adverse events among ambulatory diabetes patients. Citation Text: Sarkar U, Handley MA, Gupta R, et al. Use of an interactive, telephone-based self-management support program to identify adverse ev…

785. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36352/psn-pdf
     April 14, 2011 - Patient expectations of fair complaint handling in hospitals: empirical data. April 14, 2011 Friele RD, Sluijs EM. Patient expectations of fair complaint handling in hospitals: empirical data. BMC Health Serv Res. 2006;6:106. https://psnet.ahrq.gov/issue/patient-expectations-fair-complaint-handling-hospitals-empir…

786. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50838/psn-pdf
     January 29, 2020 - Start the new year off right by preventing these top 10 medication errors and hazards. January 29, 2020 ISMP Medication Safety Alert! Acute care edition. January 16, 2020;26(2):1-6. https://psnet.ahrq.gov/issue/start-new-year-right-preventing-these-top-10-medication-errors-and-hazards Medication errors routinely c…

787. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/854639/psn-pdf
     October 18, 2023 - Right Kind of Wrong: Why Learning to Fail can Teach us to Thrive. October 18, 2023 Edmondson A. Atria Books, New York, 2023. ISBN: 9781982195069. https://psnet.ahrq.gov/issue/right-kind-wrong-why-learning-fail-can-teach-us-thrive Despite the harm that failure can cause, its value as a learning opportunity, if exam…

788. 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…

789. 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

790. 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…

791. 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…

792. 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

793. 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…

794. 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…

795. 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…

796. 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…

797. 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…

798. 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…

799. 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

800. 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…