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Showing results for "happen".

81. 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

82. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/851071/psn-pdf
    June 28, 2023 - Inside the preventable deaths that happened within a prominent transplant center. June 28, 2023 Blau M. ProPublica. June 14, 2023. https://psnet.ahrq.gov/issue/inside-preventable-deaths-happened-within-prominent-transplant-center Medical errors during organ transplants can have catastrophic consequences. This repo…

83. 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

84. 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

85. 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

86. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/46506/psn-pdf
    October 11, 2017 - Getting Ahead of Harm Before It Happens: A Guide About Proactive Analysis for Improving Surgical Care Safety. October 11, 2017 Wiley K, Davies JM. Edmonton, AB: Canadian Patient Safety Institute; 2017. https://psnet.ahrq.gov/issue/getting-ahead-harm-it-happens-guide-about-proactive-analysis-improving- surgical-car…

87. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/50677/psn-pdf
    November 20, 2019 - What Happens When Doctors Make Diagnostic Errors? November 20, 2019 The Peoples Pharmacy. Show 1186: National Public Radio. October 24, 2019. https://psnet.ahrq.gov/issue/what-happens-when-doctors-make-diagnostic-errors Misdiagnosis growing area of concern in health care. This radio feature explores three commonly …

88. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/47944/psn-pdf
    April 17, 2019 - how-deliver-safer-and-effective-patient-care-tips-team-leaders-and-educators https://psnet.ahrq.gov/issue/adverse-outcomes-why-bad-things-happen-good-people

89. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/50719/psn-pdf
    December 04, 2019 - A lot happens when you report a hazard or error to ISMP—there’s no “black hole” here! December 4, 2019 ISMP Medication Safety Alert! Acute Care Edition. November 7, 2019 https://psnet.ahrq.gov/issue/lot-happens-when-you-report-hazard-or-error-ismp-theres-no-black-hole-here The reporting and analysis of incidents i…

90. Safely Home: What Happens When People Leave Hospital Care Settings? | PSNet
    psnet.ahrq.gov/issue/safely-home-what-happens-when-people-leave-hospital-care-settings
    August 02, 2023 - Book/Report Safely Home: What Happens When People Leave Hospital Care Settings? Citation Text: Safely Home: What Happens When People Leave Hospital Care Settings? London, UK: Healthwatch England; July 2015. Copy Citation Save Save to your library Print D…

91. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/50606/psn-pdf
    October 30, 2019 - One doctor. 25 deaths. How could it have happened? October 30, 2019 Healy J, Farr I, Feiger L, Duffy C. New York Times. October 11, 2019. https://psnet.ahrq.gov/issue/one-doctor-25-deaths-how-could-it-have-happened Systemic failures persistently undermine processes meant to keep patients safe. This news story discu…

92. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/866746/psn-pdf
    September 18, 2024 - https://psnet.ahrq.gov/primer/leadership-role-improving-safety https://psnet.ahrq.gov/issue/could-it-happen-here-learning-other-organizations-safety-errors

93. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/844987/psn-pdf
    February 22, 2023 - examining-medication-ordering-errors-using-ahrq-network-patient-safety- databases Medication errors can happen

94. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/47375/psn-pdf
    November 02, 2018 - ethical-duty-health-care-systems-address-interfacility-medical-error-discovery https://psnet.ahrq.gov/issue/could-it-happen-here-learning-other-organizations-safety-errors

95. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/841481/psn-pdf
    January 01, 2023 - trainees-perceptions-being-allowed-fail-clinical-training-sense-making-model https://psnet.ahrq.gov/issue/surgical-errors-happen-are-learners-trained-recover-them-survey-north-american-surgical

96. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/50922/psn-pdf
    February 19, 2020 - organisation-memory-report-expert-group-learning-adverse-events-nhs-chaired-chief-medical https://psnet.ahrq.gov/issue/could-it-happen-here-learning-other-organizations-safety-errors

97. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/850358/psn-pdf
    June 14, 2023 - What Happened to Patient Safety. June 14, 2023 Sheridan S. Turn on the Lights. Institute for Healthcare Improvement.  May 2023 https://psnet.ahrq.gov/issue/what-happened-patient-safety Patient engagement is an important component in patient safety. This episode from the Turn on the Lights podcast (hosted by I…

98. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/42942/psn-pdf
    February 22, 2024 - elimination-emergency-department-medication-errors-due-estimated-weights https://psnet.ahrq.gov/issue/could-it-happen-here-learning-other-organizations-safety-errors

99. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/33788/psn-pdf
    June 01, 2015 - , and the definition is serious and harmful, largely preventable, patient safety issues—harms that happen … ; medication errors should never happen. … So we are eager to work with the electronic data world in order to make that happen. … But it's very hard to measure something that doesn't happen. … The patient safety world is all about measuring when mistakes or bad things happen.

100. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47885/psn-pdf
     May 01, 2019 - Deny, Dismiss, Dehumanise: What Happened When I Went to Hospital. May 1, 2019 Cullen A. Uitgeverij van Brug: The Hague, The Netherlands; 2019. ISBN: 9789065232236. https://psnet.ahrq.gov/issue/deny-dismiss-dehumanise-what-happened-when-i-went-hospital Patient stories offer important insights regarding the impact m…