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Showing results for "happen".

281. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47757/psn-pdf
     February 06, 2019 - Doctors make mistakes. A new documentary explores what happens when they do—and how to fix it. February 6, 2019 Park A. Time Magazine. January 24, 2019. https://psnet.ahrq.gov/issue/doctors-make-mistakes-new-documentary-explores-what-happens-when-they- do-and-how-fix-it This news article reports on the documentar…

282. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46506/psn-pdf
     October 11, 2017 - Getting Ahead of Harm Before It Happens: A Guide About Proactive Analysis for Improving Surgical Care Safety. October 11, 2017 Wiley K, Davies JM. Edmonton, AB: Canadian Patient Safety Institute; 2017. https://psnet.ahrq.gov/issue/getting-ahead-harm-it-happens-guide-about-proactive-analysis-improving- surgical-car…

283. Comparing Quality Scores to an Independent Standard | Agency for Healthcare Research and Quality
     www.ahrq.gov/talkingquality/translate/compare/choose/standard.html
     January 01, 2023 - These events are preventable and should never happen.”

284. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36499/psn-pdf
     January 07, 2011 - Web-based reporting system to monitor types of medication errors and near misses, determine when they happen

285. Video-Transcript-Spanish (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module3/video-transcript-spanish.docx
     June 02, 2025 - Unfortunately, things like this happen. … I hope that doesn´t happen to me. What should I do? ¿En serio? Espero que no me pase lo mismo. … It was an honest mistake, which won´t happen again. I´m sorry.

286. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50677/psn-pdf
     November 20, 2019 - What Happens When Doctors Make Diagnostic Errors? November 20, 2019 The Peoples Pharmacy. Show 1186: National Public Radio. October 24, 2019. https://psnet.ahrq.gov/issue/what-happens-when-doctors-make-diagnostic-errors Misdiagnosis growing area of concern in health care. This radio feature explores three commonly …

287. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/841305/psn-pdf
     January 27, 2023 - It was always a draft because as the day evolved, things would happen that changed that plan. … All patient care events happen in the context of other people and other parts of the system. … It’s the idea that we think that work—like providing healthcare—will happen a certain way, but when … work actually happens, people often have to make adjustments to make the work happen effectively and

288. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33878/psn-pdf
     April 01, 2019 - Politically, how were they able to make that happen? JM: The history is interesting. … Often an investigation needs to happen to elucidate the facts if it's a complex error.

289. In Conversation With… Michael Cohen, RPh, MS, ScD (hon) | PSNet
     psnet.ahrq.gov/perspective/conversation-michael-cohen-rph-ms-scd-hon-0
     October 24, 2021 - We thought for sure that many errors that might have happened in the past wouldn't happen. … We have some really dangerous errors that happen. … A lot of that can happen at the counseling stage, where there's some communication between the pharmacist … And what is the pharmacy chain doing to make sure that something like that doesn't happen?" … supervisor's fault for not addressing the issue to make it much more unlikely or even impossible to happen

290. Ambulatory Procedure/Surgery Center Survey on Patient Safety (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/asc-survey-english.docx
     June 02, 2025 - Staff are told about patient safety problems that happen in this facility ........................... … We are good at changing processes to make sure the same patient safety problems don’t happen again

291. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50719/psn-pdf
     December 04, 2019 - A lot happens when you report a hazard or error to ISMP—there’s no “black hole” here! December 4, 2019 ISMP Medication Safety Alert! Acute Care Edition. November 7, 2019 https://psnet.ahrq.gov/issue/lot-happens-when-you-report-hazard-or-error-ismp-theres-no-black-hole-here The reporting and analysis of incidents i…

292. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33789/psn-pdf
     August 01, 2015 - Interoperability, systems that can talk to each other, I don't think will happen on its own in that … or in some cases actually detrimental to making it happen. … Government has a role to convene and build incentives and maybe requirements to make it happen. … The market will not make privacy and security happen well enough by itself. … Some of that will happen with the same changes that promote interoperability.

293. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73534/psn-pdf
     July 28, 2021 - its-big-part-being-good-surgeons-surgical-trainees-perceptions-error-recovery-operating-room https://psnet.ahrq.gov/issue/surgical-errors-happen-are-learners-trained-recover-them-survey-north-american-surgical

294. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/844047/psn-pdf
     February 08, 2023 - failure, the process of allowing or interrupting failure, and how they decide to allow failure to happen

295. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50606/psn-pdf
     October 30, 2019 - One doctor. 25 deaths. How could it have happened? October 30, 2019 Healy J, Farr I, Feiger L, Duffy C. New York Times. October 11, 2019. https://psnet.ahrq.gov/issue/one-doctor-25-deaths-how-could-it-have-happened Systemic failures persistently undermine processes meant to keep patients safe. This news story discu…

296. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/851071/psn-pdf
     June 28, 2023 - Inside the preventable deaths that happened within a prominent transplant center. June 28, 2023 Blau M. ProPublica. June 14, 2023. https://psnet.ahrq.gov/issue/inside-preventable-deaths-happened-within-prominent-transplant-center Medical errors during organ transplants can have catastrophic consequences. This repo…

297. TeamSTEPPS® Diagnosis Improvement: Module 4 Leadership - Facilitator’s Notes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module4-presenters-notes.pdf
     January 05, 2022 - These  examples  can  be  from  actual  experience  or  situations  that  you  imagine could happen. … Slide 11 could happen. 3. … • How could that happen in your setting? … • Did everything happen for a patient or patients that was intended? … These  examples  can  be from  actual  experience  or  situations  that  you  imagine  could  happen

298. Strategy 3: Bedside Shift Report (Tool 2) (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy3/Strat3_Tool_2_Nurse_Chklst_508.docx
     June 02, 2025 - “What do you want to happen during the next 12 hours?”

299. Sensemaking and Learn From Defects for Perinatal Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-slides.html
     July 01, 2023 - Question 2: Why did it happen? Question 3: What will you do to reduce the risk of reoccurrence? … Defects or failures are clinical or operational events that you do not want to happen again.

300. The Science of Improving Patient Safety
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/understand/scisafety.pptx
     March 01, 2009 - deaths from central line-associated blood stream infections per year8 4 4 How Can These Errors Happen … Why did it happen? How will you reduce the risk of recurrence? How will you know it worked?