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Total Results: 4,075 records

Showing results for "happen".

  1. Psn-Pdf (pdf file)

    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…

  2. Psn-Pdf (pdf file)

    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

  3. Identify Defects Module Alternate Text | Agency for Healthcare Research and Quality

    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

  4. Psn-Pdf (pdf file)

    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

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848092/psn-pdf
    April 26, 2023 - Doctors must stop tuning out Black women. It happened to me, as a pregnant OB-GYN. April 26, 2023 Gillispie-Bell V. USA Today. April 14, 2023. https://psnet.ahrq.gov/issue/doctors-must-stop-tuning-out-black-women-it-happened-me-pregnant-ob-gyn Structural racism and implicit biases can lead to poor quality of care …

  6. Psn-Pdf (pdf file)

    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

  7. Generalized Anxiety Disorder scale, GAD-7; 7 items (pdf file)

    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

  8. Enhancing Surgical Team Communication: SOPS® and TeamSTEPPS®in Action Webcast (pdf file)

    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

  9. In Conversation with Jessica Behrhorst about The Evolution of Root Cause Analysis | PSNet

    psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evolution-root-cause-analysis
    February 26, 2025 - “Why did it happen?” “What are we doing to keep it from happening again?” … direct causes of an adverse event and the systemic weaknesses that may have allowed the event to happen

  10. The Evolution of Root Cause Analysis | PSNet

    psnet.ahrq.gov/perspective/evolution-root-cause-analysis
    February 26, 2025 - direct causes of an adverse event and the systemic weaknesses that may have allowed the event to happen … “Why did it happen?” “What are we doing to keep it from happening again?”

  11. Supplemental Items for the CAHPS Clinician & Group Adult Survey 3.0/3.1: Narrative Comments | Agency for Healthcare Research and Quality

    www.ahrq.gov/cahps/surveys-guidance/item-sets/cg/suppl-narrative-items-cg-survey30-adult.html
    August 01, 2021 - Supplemental Items for the CAHPS Clinician & Group Adult Survey 3.0/3.1: Narrative Comments Population version: Adult Learn about the CAHPS Patient Narrative Item Sets . Placing the items in the survey: Insert these supplemental items before the "About You" section of the survey. Introducing the it…

  12. Surveys on Patient Safety Culture (SOPS) Medical Office Survey: 2020 User Database Report Part I (pdf file)

    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.

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33670/psn-pdf
    July 01, 2008 - What then needs to happen is the institutions need to track what the solutions are, and they need to … serious incidents, called sentinel events, and any hospital board would like to see these things never happen … Wrong site surgeries are a pretty good example of this—they happen to every big institution a few times

  14. Presentation: Program Overview

    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

  15. In Conversation with…Robert M. Wachter, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-withrobert-m-wachter-md
    October 01, 2008 - If you are going to promulgate a policy that either publicly reports adverse events that happen in hospitals … to be sure that the hospital is not being blamed, for lack of a better word, for things that didn't happen … Sometimes patients are sent to us because they've had bad things happen—they're very ill and it's our … That in fact, hospitals should be paying for things that shouldn't happen, and that this type of policy … DRG-like system where we will pay for a given diagnosis, I think it is inevitable that when adverse events happen

  16. Psn-Pdf (pdf file)

    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

  17. Medication mix-up: what happened at Vanderbilt and how it impacts health care providers. | PSNet

    psnet.ahrq.gov/issue/medication-mix-what-happened-vanderbilt-and-how-it-impacts-health-care-providers
    March 18, 2020 - Commentary Medication mix-up: what happened at Vanderbilt and how it impacts health care providers. Citation Text: Medication mix-up: what happened at Vanderbilt and how it impacts health care providers. Michel C, Talley C. J Health Life Sci Law. 2022;17(1):71 Copy Citation …

  18. Appendix A. Teamwork and Communication Definitions and Tools | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/cauti-tools/phys-championsgd/appa.html
    October 01, 2015 - What do you want to happen by when?

  19. Community Pharmacy Survey on Patient Safety (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/community-pharmacy/pharmacy-survey-english.docx
    June 02, 2025 - We look at staff actions and the way we do things to understand why mistakes happen in this pharmacy

  20. SOPS Community Pharmacy Survey Items and Composites (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/pharmsops-composites.pdf
    June 02, 2025 - We look at staff actions and the way we do things to understand why mistakes happen in this pharmacy
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