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psnet.ahrq.gov/issue/when-mistakes-happen
May 13, 2020 - Newspaper/Magazine Article
When mistakes happen. … Citation Text:
When mistakes happen. Beck DL. ASH Clinical News. December 1, 2018. … Copy URL
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When mistakes happen
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psnet.ahrq.gov/issue/when-incidents-happen
January 14, 2011 - Commentary
When incidents happen.
Citation Text:
Newfield JS. … When Incidents Happen. Home Health Care Manag Pract. 2006;18(5). doi:10.1177/1084822306287998. … When Incidents Happen. Home Health Care Manag Pract. 2006;18(5). doi:10.1177/1084822306287998.
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psnet.ahrq.gov/issue/how-could-happen
September 19, 2007 - Newspaper/Magazine Article
How could this happen? … Citation Text:
How could this happen? Westfall SS; Mascia K. People. October 5, 2009. … Copy URL
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How could this happen
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psnet.ahrq.gov/issue/sued-misdiagnosis-it-could-happen-you
February 07, 2024 - It could happen to you.
Citation Text:
Lippman H, Davenport J. Sued for misdiagnosis? … It could happen to you. J Fam Pract. 2010;59(9):498-508. … It could happen to you. J Fam Pract. 2010;59(9):498-508.
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www.ahrq.gov/hai/cusp/videos/05h-why-did-happen/index.html
June 01, 2018 - Why Did It Happen?
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ce.effectivehealthcare.ahrq.gov/hai/cusp/videos/05h-why-did-happen/index.html
June 01, 2018 - Program
Comprehensive Unit-based Safety Program (CUSP)
Videos
Why Did It Happen … Videos
Decolonization – Universal and Targeted
Tools
Why Did It Happen … reviewed June 2018
Page originally created February 2013
Internet Citation: Why Did It Happen … https://www.ahrq.gov/hai/cusp/videos/05h-why-did-happen/index.html
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psnet.ahrq.gov/issue/medication-errors-dont-let-them-happen-you
January 21, 2015 - Commentary
Medication errors: don't let them happen to you.
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psnet.ahrq.gov/issue/events-inspired-change-importance-sharing-what-happened-stop-it-happening-again
August 07, 2024 - Commentary
Events that inspired change: the importance of sharing what happened to stop it from happening again.
Citation Text:
Myers E, Allen C. Events that inspired change: the importance of sharing what happened to stop it from happening again. Patient Saf. 2023;5(1):62-63. doi:10.339…
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psnet.ahrq.gov/web-mm/hidden-heparins-hit-happens
March 27, 2024 - SPOTLIGHT CASE
Hidden Heparins: HIT Happens
Citation Text:
Fogarty PF. Hidden Heparins: HIT Happens. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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Google Scholar BibTeX EndNote X3…
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psnet.ahrq.gov/issue/adverse-outcomes-why-bad-things-happen-good-people
August 30, 2023 - Commentary
Adverse outcomes: why bad things happen to good people. … Adverse outcomes: why bad things happen to good people. … Adverse outcomes: why bad things happen to good people.
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psnet.ahrq.gov/web-mm/what-happened-telemetry
January 18, 2012 - communication between the monitor watcher and the bedside nurse.( 11 ) Close communication clearly did not happen
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psnet.ahrq.gov/issue/hospitals-look-computers-predict-patient-emergencies-they-happen
June 16, 2021 - Article
Hospitals look to computers to predict patient emergencies before they happen … Citation Text:
Hospitals look to computers to predict patient emergencies before they happen. … Citation
Citation Text:
Hospitals look to computers to predict patient emergencies before they happen
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www.ahrq.gov/hai/cusp/videos/05g-what-happened/index.html
June 01, 2018 - What Happened?
CUSP Toolkit
The CUSP toolkit includes training tools to make care safer by improving the foundation of how your physicians, nurses, and other clinical team members work together. These videos reinforce the material presented in each module of the CUSP toolkit.
CUSP Helps Find Out What Hap…
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psnet.ahrq.gov/issue/what-happened-patient-safety
August 23, 2007 - Audiovisual
What Happened to Patient Safety.
Citation Text:
What Happened to Patient Safety. Sheridan S. Turn on the Lights. Institute for Healthcare Improvement. May 2023
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psnet.ahrq.gov/issue/could-it-happen-here-learning-other-organizations-safety-errors
February 17, 2017 - Newspaper/Magazine Article
Could it happen here? … Could it happen here? Learning from other organizations' safety errors. … Could it happen here? Learning from other organizations' safety errors.
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www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/resources/tools/implement/action-plan.html
March 01, 2017 - Steps
How will this happen? … Who will make this happen?
[Be specific for each task.] … What other information do I need to make this happen? … Steps
How will this happen? … What other information do I need to make this happen?
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psnet.ahrq.gov/issue/when-bad-things-happen-training-medical-students-anticipate-aftermath-medical-errors
July 29, 2020 - Study
When bad things happen: training medical students to anticipate the aftermath … When bad things happen: training medical students to anticipate the aftermath of medical errors. … When bad things happen: training medical students to anticipate the aftermath of medical errors. … July 29, 2020
Surgical errors happen, but are learners trained to recover from them?
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psnet.ahrq.gov/node/861286/psn-pdf
January 24, 2024 - Surgical safety does not happen by accident: learning
from perioperative near miss case studies. … Surgical safety does not happen by accident: learning
from perioperative near miss case studies. … https://psnet.ahrq.gov/issue/surgical-safety-does-not-happen-accident-learning-perioperative-near-miss … https://psnet.ahrq.gov/issue/surgical-safety-does-not-happen-accident-learning-perioperative-near-miss-case-studies … https://psnet.ahrq.gov/issue/surgical-safety-does-not-happen-accident-learning-perioperative-near-miss-case-studies
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psnet.ahrq.gov/issue/program-encourages-reporting-accidents-waiting-happen-good-catch-awards
February 13, 2013 - Newspaper/Magazine Article
Program encourages reporting accidents waiting to happen … Citation Text:
Program encourages reporting accidents waiting to happen: the Good Catch Awards. … Cite
Citation
Citation Text:
Program encourages reporting accidents waiting to happen
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/resources/tools/implement/facility-action-plan.docx
January 01, 2018 - Steps
How will this happen? … Who will make this happen?
[Be specific for each task.] … What other information do I need to make this happen? … Steps
How will this happen? … What other information do I need to make this happen?