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Showing results for "happen".

  1. Morning Briefing and Shadowing (Slide Presentation) | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/cusp/toolkit/content-calls/briefing-slides/slides.html
    October 01, 2014 - An Overview Members of the team have an understanding of what’s going on and what is likely to happen … competence Who has what skills  Who performs what  Who knows what  Predicts what will happen

  2. 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. …

  3. “I had no idea this happened”: electronic feedback on clinical reasoning for hospitalists. | PSNet

    psnet.ahrq.gov/issue/i-had-no-idea-happened-electronic-feedback-clinical-reasoning-hospitalists
    February 28, 2024 - Study “I had no idea this happened”: electronic feedback on clinical reasoning for hospitalists. Citation Text: 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. d…

  4. 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;…

  5. 162-Example-Completed-Learning-Defects-Tool (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/162-example-completed-learning-defects-tool.docx
    October 01, 2024 - A defect is any clinical or operational event that you would not want to happen again. … Why did it happen?

  6. 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…

  7. Silence A Commentary | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/reports/liability/silence.html
    August 01, 2017 - Second, we need to know that what happened to our loved one is not going to happen to anyone else.

  8. 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…

  9. Understand the Science of Safety | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/cusp/modules/understand/science-safety-notes.html
    July 01, 2018 - How Can These Errors Happen? Slide 6. The Science of Safety Slide 7. … Return to Contents   Slide 5: How Can These Errors Happen? … The first step in comprehending why they happen is accepting the fact that people are not perfect. … Why did it happen? What will we do to reduce the recurrence? How will we know it worked? … Why did it happen? How will you reduce the risk of recurrence? How will you know it worked?

  10. 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…

  11. 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…

  12. Learning from Patient Narratives Through Innovative Feedback Reporting Methods Webcast - Welcome from AHRQ (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/learning_pt_narratives_053123-ginsberg.pdf
    June 02, 2025 - surveys measure experience: ► What happened to the patient in the care encounter, or how often did it happen

  13. 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

  14. 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

  15. 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

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34008/psn-pdf
    March 17, 2011 - They encourage doctors and their insurers to be honest when mistakes happen, offer apologies, and provide

  17. 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

  18. Strategy 3: Nurse Bedside Shift Report (Tool 1) (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy3/Strat3_Tool_1_BSR_Broch_508.pdf
    June 02, 2025 - • If nurse bedside shift report does not happen, call the nurse manager at [insert phone number]

  19. 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…

  20. 124-Cusp-Science-Safety-Fg (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/124-cusp-science-safety-fg.docx
    April 01, 2025 - address other system factors, because defects in the system increase the likelihood that the error will happen … prevents infusions from running too fast is an example of a latent failure that enabled the defect to happen … Latent failures are the “holes in the system”—the weaknesses that could allow an active failure to happen … Slide 18 Swiss Cheese Model: How Errors Happen SAY: Sometimes defenses fail, and errors line up, … These adverse outcomes are our “defects”—the events that occur and we don’t want them to happen again
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