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psnet.ahrq.gov/perspective/patient-safety-and-health-information-technology-learning-our-mistakes
July 01, 2012 - Patient Safety and Health Information Technology: Learning from Our Mistakes
Ross Koppel, PhD | July 1, 2012
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View more articles from the same authors.
Citation Text:
Koppel R. Patient Safety and Health Information Technology: Learning f…
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psnet.ahrq.gov/perspective/medical-scribes-and-patient-safety
August 01, 2019 - That was not going to happen. … Again, most of that change is going to happen in the beginning month or two as you start using a scribe
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psnet.ahrq.gov/perspective/conversation-james-augustine-md
July 28, 2021 - EMS quality improvement begins when the EMS providers know what would happen in ideal circumstances but
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psnet.ahrq.gov/issue/uncovering-shocking-dangers-misdiagnosis
May 13, 2020 - Audiovisual
Uncovering the shocking dangers of misdiagnosis.
Citation Text:
Uncovering the shocking dangers of misdiagnosis. Graedon T. People’s Pharmacy. Show 1355. September 8, 2023.
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www.ahrq.gov/sites/default/files/2025-02/jones-selna-report.pdf
January 01, 2025 - Final Progress Report: Inpatient-Outpatient Transitions: Reducing the Rate of Readmissions
FINAL REPORT
Title of Project: Inpatient-Outpatient Transitions: Reducing the Rate of
Readmissions
Principal Investigator: J.B. Jones, PhD, MBA
Mark J. Selna (original Principal Investigator)
Team Members: Mark Selna, MD
…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy3/Strat3_Implement_Hndbook_508.pdf
August 01, 2010 - After the training, it is important to assess:
• Did the training happen as planned? … Committed nurse
champions at the unit and
floor levels make sure that
bedside shift report
continues to happen
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-101-webcast-transcript.pdf
January 01, 2019 - experience because what patient experience is getting at is really whether something happened or didn't
happen
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www.ahrq.gov/sites/default/files/2024-12/karsh-report.pdf
January 01, 2024 - It is read as the column
can cause the row to happen.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-implementation-handouts.docx
July 01, 2016 - Nurse Manager A: We can make it happen.
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/handouts.html
December 01, 2017 - Nurse Manager A: We can make it happen.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/nursing-home/2016/nhsurv16-pt1.pdf
January 01, 2016 - Organizational Learning
This nursing home lets the same mistakes happen again
and again. … This nursing home lets the same mistakes happen
again and again. … residents safe”) and a negatively worded item (such as, “This nursing home lets the same
mistakes happen
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psnet.ahrq.gov/node/33791/psn-pdf
September 01, 2015 - have
this great EHR, you should be harnessing it for safety, but these transcription errors still happen
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www.ahrq.gov/sites/default/files/publications/files/obesity-pcpresources.pdf
May 01, 2014 - What didn’t happen? There was no discussion of diet and nutrition as part of Ms. … Why didn’t it happen? … • What do you think will happen if you don’t change anything about your weight?
Closed Example 1. … • What do you want to have happen?
Affirmations. … This can
happen in any number of ways.
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digital.ahrq.gov/sites/default/files/docs/citation/asthmacarewithhit_081011comp.pdf
July 01, 2011 - nonchalance to be an
indication of a successful test, in that everything that the users expected to happen … did happen,
without the users having to confront any of the underlying challenges associated with achieving … by administrative and fiscal challenges that the project team faced,
when it considered what would happen
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psnet.ahrq.gov/node/33855/psn-pdf
April 01, 2018 - Every patient
is different and things happen in the hospitalization, so to get the acute situation under
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_4-situation-monitoring.pptx
July 01, 2023 - identify new or changing information
Create individual awareness of what’s going on and what is likely to happen … Unfortunately, the reality of patient care is such that sometimes surprises happen or a case is complex … about the patient's clinical status, what interventions have been performed thus far, and what needs to happen
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psnet.ahrq.gov/primer/readmissions-and-adverse-events-after-discharge
April 27, 2022 - Readmissions and Adverse Events After Discharge
Citation Text:
Readmissions and Adverse Events After Discharge. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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www.ahrq.gov/sites/default/files/wysiwyg/mcc/pccp4p/baseline-scan-appendices.pdf
February 22, 2024 - and considers that this is always a process of re-
examination and refinement, because many things happen … KIs thought engagement needed to
happen through multiple mediums,
including utilizing virtual formats … includes and considers that this is always a process of re-examination and refinement, because many things happen … -Health services researcher
KIs thought engagement needed to happen through multiple mediums, including
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.200_slideshow.ppt
May 01, 2009 - Spotlight Case July 2008
Spotlight Case
Delirium or Dementia?
Source and Credits
This presentation is based on the May 2009
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: James L. Rudolph, MD, SM
Editor, AHRQ WebM&M: Robert Wachter, MD
Sp…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.64_slideshow.ppt
June 01, 2004 - Spotlight Case [MONTH] 2003
Spotlight Case June 2004
The Wrong Shot:
Error Disclosure
Source and Credits
This presentation is based on the June 2004
AHRQ WebM&M Spotlight Case in Pediatrics
CME credit is available through the Web site
See the full article at http://webmm.ahrq.gov
Commentary by: Thomas H. …