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psnet.ahrq.gov/issue/safely-home-what-happens-when-people-leave-hospital-care-settings
August 02, 2023 - Book/Report
Safely Home: What Happens When People Leave Hospital Care Settings?
Citation Text:
Safely Home: What Happens When People Leave Hospital Care Settings? London, UK: Healthwatch England; July 2015.
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www.ahrq.gov/hai/tools/surgery/modules/on-boarding/science-of-safety-fac-notes.html
December 01, 2017 - Slide 6: How Do These Errors Happen? … Say:
Errors happen because people are fallible. … a powerful exercise in which teams evaluate their processes to identify gaps that allow mistakes to happen … Simply put, a defect is any clinical or operational event or situation that you would not want to happen
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psnet.ahrq.gov/node/850358/psn-pdf
June 14, 2023 - What Happened to Patient Safety.
June 14, 2023
Sheridan S. Turn on the Lights. Institute for Healthcare Improvement. May 2023
https://psnet.ahrq.gov/issue/what-happened-patient-safety
Patient engagement is an important component in patient safety. This episode from the Turn on the Lights
podcast (hosted by I…
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/gout_consumer.pdf
January 01, 2017 - The joint most often affected is the
big toe, but gout can happen in any joint (such as the ankles, … But, an attack can happen again. Over time, attacks may last longer
and may happen more often. … � Side effects happen about as often with allopurinol (Zyloprim®)
as with febuxostat (Uloric®).
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psnet.ahrq.gov/node/42346/psn-pdf
June 10, 2018 - Fatal PCA adverse events continue to happen...better
patient monitoring is essential to prevent harm
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psnet.ahrq.gov/node/35766/psn-pdf
March 02, 2011 - presented to illustrate the importance of bridging what happens at the
bedside with what needs to happen
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digital.ahrq.gov/ahrq-funded-projects/theory-based-patient-portal-elearning-program-older-adults-chronic-illnesses/citation/patient
January 01, 2023 - Patient portal use among older adults: what Is really happening nationwide?
Citation
Nahm ES, Zhu S, Bellantoni M, et al. Patient portal use among older adults: what Is really happening nationwide? J Appl Gerontol 2018 May 1:733464818776125. doi:10.1177/0733464818776125. [Epub ahead of print]. PMID: 2…
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psnet.ahrq.gov/perspective/conversation-james-p-bagian-md-pe
February 26, 2025 - The way I would look at it is to try to understand what happened, why did it happen, and what do you … Why did it happen? What are we going to do to prevent it in the future? … Our goal is to make sure that this cannot or is very unlikely to happen in the future and whether there's … Unfortunately, in today's health care industry there are many places where that doesn't happen.
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psnet.ahrq.gov/node/850346/psn-pdf
June 14, 2023 - coping-errors-operating-room-intraoperative-strategies-postoperative-strategies-and-sex
https://psnet.ahrq.gov/issue/surgical-errors-happen-are-learners-trained-recover-them-survey-north-american-surgical
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integrationacademy.ahrq.gov/sites/default/files/2020-07/GAD-7.pdf
January 01, 2020 - Feeling afraid as if something awful might 0 1 2 3
happen
Add the score for each column
Total
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psnet.ahrq.gov/node/866583/psn-pdf
August 28, 2024 - assessing-stops-framework-coping-intraoperative-errors-evidence-efficacy-hints-hubris-and
https://psnet.ahrq.gov/issue/surgical-errors-happen-are-learners-trained-recover-them-survey-north-american-surgical
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psnet.ahrq.gov/issue/deny-dismiss-dehumanise-what-happened-when-i-went-hospital
September 09, 2015 - Book/Report
Deny, Dismiss, Dehumanise: What Happened When I Went to Hospital.
Citation Text:
Deny, Dismiss, Dehumanise: What Happened When I Went to Hospital. Cullen A. Uitgeverij van Brug: The Hague, The Netherlands; 2019. ISBN: 9789065232236.
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…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/05-sops-teamstepps-webcast-mazur.pdf
April 30, 2022 - Communication; 1 unit data only)
Communication about error 82 +15
We are informed about errors that happen … in this unit. 80 +15
When errors happen in this unit, we discuss ways to
prevent them from happening
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www.ahrq.gov/hai/cusp/toolkit/content-calls/business-case.html
April 01, 2013 - set the stage with this one, that if you do the improvements in quality and patient safety, what can happen … It isn’t going to happen. … Let’s go to slide number 25 and take a look at what does happen to hospital throughput. … What would happen if you put a sign up in your hospital that said, 25 minutes since our last hospital … You’re spending more, but what’s going to happen is you’ll stop the spread of infection from staff to
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www.ahrq.gov/hai/cusp/modules/identify/alt-text.html
March 01, 2013 - Why did it happen?
What will you do to reduce the risk of recurrence? … (vignette still)
Click to play
Video icon
Slide 23
Why Did It Happen? … several common themes
Defects or failures are clinical or operational events that you do not want to happen
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psnet.ahrq.gov/node/33686/psn-pdf
August 01, 2009 - time at the right dose without asking the nurses to do endless workarounds to
make sure that will all happen … Now without stopping the work, what could happen at that point is that the nurse does go procure the … RW: Does this not happen in health care because the nurse doesn't think about her work that way? … If you look at the financial
market, what will happen is that for all the finger pointing that's going … Maybe the first measures are very simple: yes or no, did a never event
happen?
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psnet.ahrq.gov/node/45936/psn-pdf
March 08, 2017 - using-information-external-errors-signal-clear-and-present-danger
https://psnet.ahrq.gov/issue/could-it-happen-here-learning-other-organizations-safety-errors
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/science-of-safety-slides.pptx
January 01, 2017 - Science of Safety ‹#›
AHRQ Safety Program for Mechanically Ventilated Patients
4
Errors Happen Because … individual doctors and nurses
Health care systems are rarely designed to catch mistakes before they happen
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psnet.ahrq.gov/node/73222/psn-pdf
May 05, 2021 - Fatal mistakes: why do ten-fold medication errors in
children keep happening?
May 5, 2021
Parry C. The Pharmaceutical Journal. April 22 2021.
https://psnet.ahrq.gov/issue/fatal-mistakes-why-do-ten-fold-medication-errors-children-keep-happening
Weight-based prescribing in children harbors challenges to accura…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/2020_MOSOPS_Part_I-rev0921.pdf
January 01, 2020 - (F2)
Mistakes happen more than they should
in this office . … (E1R)
They overlook patient care mistakes that
happen over and over. … This office is good at changing office processes to make
sure the same problems don’t happen again. … Mistakes happen more than they should in this office. … They overlook patient care mistakes that happen over
and over.