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Total Results: 4,075 records

Showing results for "happen".

  1. Drug error at Eskenazi Hospital killed prominent cancer researcher. Here's how it happened. | PSNet

    psnet.ahrq.gov/issue/drug-error-eskenazi-hospital-killed-prominent-cancer-researcher-heres-how-it-happened
    September 09, 2015 - Newspaper/Magazine Article Drug error at Eskenazi Hospital killed prominent cancer researcher. Here's how it happened. Citation Text: Drug error at Eskenazi Hospital killed prominent cancer researcher. Here's how it happened. Evans T. Indianapolis Star. October 30, 2020. Copy Citatio…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47375/psn-pdf
    November 02, 2018 - ethical-duty-health-care-systems-address-interfacility-medical-error-discovery https://psnet.ahrq.gov/issue/could-it-happen-here-learning-other-organizations-safety-errors

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47061/psn-pdf
    July 25, 2018 - measuring-preventable-harm-helping-science-keep-pace-policy https://psnet.ahrq.gov/issue/adverse-outcomes-why-bad-things-happen-good-people

  4. The Power of Patient Stories for Improving the Patient Experience webcast - Nembhard (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/patient-narratives-webinar-quality.pdf
    June 02, 2025 - The Power of Patient Stories for Improving the Patient Experience webcast - Nembhard Using Narratives for Quality Improvement Ingrid Nembhard, PhD, MS Fishman Family President’s Distinguished Associate Professor of Health Care Management Disclosures This work was funded by the Agency for Healthcare Research a…

  5. Learning-Antibiotic-Adverse-Events-Form (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/learning-antibiotic-adverse-events-form.docx
    November 01, 2019 - or situation involving the prescription or administration of antibiotics that you would not want to happen

  6. What happened to my patient? An educational intervention to facilitate postdischarge patient follow-up. | PSNet

    psnet.ahrq.gov/issue/what-happened-my-patient-educational-intervention-facilitate-postdischarge-patient-follow
    June 22, 2022 - Commentary What happened to my patient? An educational intervention to facilitate postdischarge patient follow-up. Citation Text: Narayana S, Rajkomar A, Harrison JD, et al. What Happened to My Patient? An Educational Intervention to Facilitate Postdischarge Patient Follow-Up. J Grad Med…

  7. Assessing TAKEheart | Agency for Healthcare Research and Quality

    www.ahrq.gov/takeheart/assessing/index.html
    August 01, 2023 - Assessing TAKEheart Through our assessment of TAKEheart, we learned many lessons that will help guide future work in this area. Our Evaluation Report Executive Summary describes the project activities, key findings, lessons learned, and recommendations for future similar efforts. Our Hybrid Cardiac Rehabilita…

  8. What happens between visits? Adverse and potential adverse events among a low-income, urban, ambulatory population with diabetes. | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/harnessing-health-information-technology-self-management-support-and-medicati-7
    January 01, 2023 - What happens between visits? Adverse and potential adverse events among a low-income, urban, ambulatory population with diabetes. Citation Sarkar U, Handley MA, Gupta R, et al. What happens between visits? Adverse and potential adverse events among a low-income, urban, ambulatory population with diabe…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33820/psn-pdf
    December 01, 2016 - 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.

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866848/psn-pdf
    September 25, 2024 - We can make sure these processes happen the right way every time. … You cannot force that care pathway to happen a certain way every time. … And you do not know what is going to happen. … kind of thing where you can say, “Zero things will go wrong,” because I don't know how it's going to happen

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33867/psn-pdf
    October 01, 2018 - 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?" … and many vendors are making it available now for the first time, called CancelRx, but that doesn't happen

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34691/psn-pdf
    May 18, 2016 - human errors will occur and that are designed to minimize their occurrence and absorb them when they happen

  13. Doctors make mistakes. A new documentary explores what happens when they do—and how to fix it. | PSNet

    psnet.ahrq.gov/issue/doctors-make-mistakes-new-documentary-explores-what-happens-when-they-do-and-how-fix-it
    November 20, 2019 - Newspaper/Magazine Article Doctors make mistakes. A new documentary explores what happens when they do—and how to fix it. Citation Text: Doctors make mistakes. A new documentary explores what happens when they do—and how to fix it. Park A. Time Magazine. January 24, 2019. Copy Citation…

  14. Doctors must stop tuning out Black women. It happened to me, as a pregnant OB-GYN. | PSNet

    psnet.ahrq.gov/issue/doctors-must-stop-tuning-out-black-women-it-happened-me-pregnant-ob-gyn
    June 24, 2020 - Newspaper/Magazine Article Doctors must stop tuning out Black women. It happened to me, as a pregnant OB-GYN. Citation Text: Doctors must stop tuning out Black women. It happened to me, as a pregnant OB-GYN. Gillispie-Bell V. USA Today. April 14, 2023. Copy Citation S…

  15. A lot happens when you report a hazard or error to ISMP—there’s no “black hole” here! | PSNet

    psnet.ahrq.gov/issue/lot-happens-when-you-report-hazard-or-error-ismp-theres-no-black-hole-here
    December 27, 2018 - Newspaper/Magazine Article A lot happens when you report a hazard or error to ISMP—there’s no “black hole” here! Citation Text: A lot happens when you report a hazard or error to ISMP—there’s no “black hole” here! ISMP Medication Safety Alert! Acute Care Edition. November 7, 2019 Cop…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43779/psn-pdf
    May 28, 2015 - debriefing in the emergency department, this commentary outlines how to determine when a debrief should happen

  17. An Overview of the CANDOR Process

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4/module4-event-reporting-investigation-analysis.pptx
    September 10, 2015 - and Analysis is that managing individual performance alone does not ensure that a harm event won’t happen … focusing on individual blame. 11 System And Individual Accountability2 Module 4 12 Why did the event happen

  18. Facilitator Guide: Science of Safety Training & Identifying Defects (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_scienceofsafety_facnotes.docx
    December 01, 2017 - Slide 5 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

  19. Chapter 5. Summary | Agency for Healthcare Research and Quality

    www.ahrq.gov/ncepcr/tools/obesity-kit/obtoolkit5.html
    March 01, 2014 - be translatable to any community resource and any practice willing to take the extra step to make it happen

  20. Physician Office (pdf file)

    digital.ahrq.gov/sites/default/files/docs/workflowtoolkit/Workflow_Assessment_Checklist.pdf
    June 01, 2005 - Phone in advance Phone for same day appointment Previous visit Does anything happen between
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