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Showing results for "happen".

  1. Mod5-Disclosure-Checklist (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/mod5-disclosure-checklist.pdf
    April 01, 2016 - Purpose: To provide guidance to individuals who are conducting initial or followup disclosure conversations, including key disclosure communication skills. Who should use this tool? Disclosure Lead and any staff who will be engaged in disclosure conversations. How to use this tool: Use Part I of the checklist to pre…

  2. Disclosure Checklist | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/checklist5.html
    August 01, 2022 - Disclosure Checklist AHRQ Communication and Optimal Resolution Toolkit Purpose: To provide guidance to individuals who are conducting initial or followup disclosure conversations, including key disclosure communication skills. Who should use this tool? Disclosure Lead and any staff who will be engaged in …

  3. 170-Cusp-Science-Safety-Notes (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/170-cusp-science-safety-notes.docx
    October 01, 2024 - Slide 15 Beyond Personal Responsibility SAY: When errors happen, we are often quick to focus on the … the individual provider—and not addressing the other system factors means the defect will eventually 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: But sometimes defenses fail, and errors line … These adverse outcomes are our “defects”—the events that occur and we don’t want them to happen again

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

    www.ahrq.gov/hai/cusp/modules/understand/science-safety-slides.html
    July 01, 2018 - How Can These Errors Happen? Slide 6. The Science of Safety Slide 7. … line-associated blood stream infections per year. 8 Return to Contents   Slide 5: How Can These Errors Happen … Why did it happen? How will you reduce the risk of recurrence? How will you know it worked?

  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/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. …

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73331/psn-pdf
    May 26, 2021 - issue/cancer-diagnoses-delayed-among-prisoners-washington-state https://psnet.ahrq.gov/issue/could-it-happen-here-learning-other-organizations-safety-errors

  8. 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.

  9. 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;…

  10. 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…

  11. Inside the preventable deaths that happened within a prominent transplant center. | PSNet

    psnet.ahrq.gov/issue/inside-preventable-deaths-happened-within-prominent-transplant-center
    May 02, 2018 - Newspaper/Magazine Article Inside the preventable deaths that happened within a prominent transplant center. Citation Text: Inside the preventable deaths that happened within a prominent transplant center. Blau M. ProPublica. June 14, 2023. Copy Citation Save S…

  12. 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…

  13. 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…

  14. 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…

  15. 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

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867190/psn-pdf
    November 20, 2024 - This article introduces why diagnostic errors happen, commonly misdiagnosed conditions, and strategies

  17. 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]

  18. Management of Insomnia Disorder (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/pdf/insomnia_consumer.pdf
    August 01, 2017 - But for people with insomnia disorder, sleep problems happen at least 3 nights each week for at least … This may happen because of habits you formed because of your insomnia (such as napping, getting in bed … Or, it may happen because of changes in the ways you think or feel about sleep (such as worrying about … Insomnia disorder can also sometimes happen on its own with no known cause. … � What specific sleep problems am I having, and how often do they happen?

  19. 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

  20. 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…
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