Results

Total Results: 3,987 records

Showing results for "happen".

2481. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/860015/psn-pdf
      September 01, 2024 - generally considered to have experienced a “never event”, a safety event that is never supposed to happen

2482. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2022-10/spotlight_case_missed_pneumothorax_10.09.2022_-_final.pdf
      January 01, 2022 - post- procedural pneumothorax with CXR, interpretation and communication of the CXR results did not happen

2483. The Wrong Channel | PSNet
      psnet.ahrq.gov/web-mm/wrong-channel
      February 01, 2003 - As we read about them (luckily, they never happen to us , of course), we are prompted to ask: Which

2484. Ventricular Wall Injury during a Diagnostic Cardiac Catheterization | PSNet
      psnet.ahrq.gov/web-mm/ventricular-wall-injury-during-diagnostic-cardiac-catheterization
      September 01, 2012 - Ultimately, this case is an excellent example of what can happen when best practices are not followed

2485. The Rationale for Case Mix and Mode Adjustments - Elliott (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/3-case-mix-mode-adjustments-webcast-elliott.pdf
      June 02, 2025 - same hospitals 32 The Effect of Adjustments • Mode adjustments can be substantial because they happen

2486. Rapid Response for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/rapid-response/rapid-response-fac-guide.html
      July 01, 2023 - plan is through briefings and team management, being aware of what is going on and what is likely to happen

2487. Labor and Delivery Unit Safety: Shoulder Dystocia | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/labor-delivery-unit/tool-shoulder-dystocia.html
      July 01, 2023 - Being aware of what is going on and what is likely to happen next.

2488. Frequently Asked Questions: The Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/faqs-final508.pdf
      June 02, 2025 - patients who are scheduled to identify those times where a Warm Handoff Plus is (a) more likely to happen

2489. Module 2: Communication and Optimal Resolution (CANDOR) Toolkit Module 2: Obtaining Organizational Buy-in and Support
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module2/module2-obtaining-organizational-buy-in-support.pptx
      August 14, 2015 - This model describes what must happen to achieve system-wide change; it also reinforces the vital role

2490. Pressure Ulcer Prevention Toolkit (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module2/putoolkit_module2_tools.docx
      February 16, 2011 - describe key processes in your organization where pressure ulcer prevention activities could or should happen

2491. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33683/psn-pdf
      April 01, 2009 - That is likely to happen through a combination of other policy tools, such as pay-for-performance and

2492. Around the Block | PSNet
      psnet.ahrq.gov/web-mm/around-block
      March 04, 2020 - If he did not, how could this happen?

2493. Creating an Environment of Consensus –The challenges of implementing a governance structure to run an HIE (pdf file)
      digital.ahrq.gov/sites/default/files/docs/page/2006Estrin_Trk4_051311comp.pdf
      March 08, 2006 - No hidden agendas  Must provide value to those who participate  This (HIE/RHIO) will be happen.

2494. Treating Disruptive Behavior Disorders in Children and Teens (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/pdf/disruptive-behavior-disorder_consumer.pdf
      August 01, 2016 - Outbursts happen with little or no warning. They usually last for 30 minutes or less.

2495. Wrong Turn through Colon: Misplaced PEG | PSNet
      psnet.ahrq.gov/web-mm/wrong-turn-through-colon-misplaced-peg
      May 01, 2017 - July 5, 2023 Prescribing errors in children: why they happen and how to prevent them.

2496. The Missing Suction Tip | PSNet
      psnet.ahrq.gov/web-mm/missing-suction-tip
      January 01, 2006 - Surgical tools left in five patients: UW surgeons take precautions to ensure it doesn’t happen again.

2497. Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules | PSNet
      psnet.ahrq.gov/web-mm/unintentional-ketamine-overdose-operating-room-mixing-ampules
      March 25, 2020 - Similar adverse drug events related to different drug concentrations in same-size ampules also happen

2498. Pocket Syringe Swap | PSNet
      psnet.ahrq.gov/web-mm/pocket-syringe-swap
      July 01, 2006 - They happen to almost every anesthesiologist sooner or later.

2499. AHRQ Webcast Introducing the New SOPS Hospital Survey 2.0 - Sorra (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/3-sorra-sops-hospital-survey-2-0-webcast.pdf
      July 20, 2020 - Positively worded survey item: We are informed about errors that happen in this unit.

2500. AHRQ Safety Program for Perinatal Care: Labor and Delivery Unit Safety Shoulder Dystocia (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/tool_shoulder-dystocia.docx
      May 01, 2017 - plan is through briefings and team management, · being aware of what is going on and what is likely to happen