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Showing results for "happen".

  1. Surgical safety does not happen by accident: learning from perioperative near miss case studies. | PSNet

    psnet.ahrq.gov/issue/surgical-safety-does-not-happen-accident-learning-perioperative-near-miss-case-studies
    August 04, 2021 - Commentary Surgical safety does not happen by accident: learning from perioperative … Surgical safety does not happen by accident: learning from perioperative near miss case studies. … Surgical safety does not happen by accident: learning from perioperative near miss case studies.

  2. What happens when things go wrong? | PSNet

    psnet.ahrq.gov/issue/what-happens-when-things-go-wrong
    April 24, 2018 - Commentary What happens when things go wrong? Citation Text: Brandom BW, Callahan P, Micalizzi DA. What happens when things go wrong? Paediatr Anaesth. 2011;21(7):730-6. doi:10.1111/j.1460-9592.2010.03513.x. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X…

  3. What happens when healthcare innovations collide? | PSNet

    psnet.ahrq.gov/issue/what-happens-when-healthcare-innovations-collide
    December 06, 2017 - Commentary What happens when healthcare innovations collide? Citation Text: Pendharkar SR, Woiceshyn J, da Silveira GJC, et al. What happens when healthcare innovations collide? BMJ Qual Saf. 2016;25(1):9-13. doi:10.1136/bmjqs-2015-004441. Copy Citation Format: DOI Google S…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47914/psn-pdf
    May 22, 2019 - Hospitals look to computers to predict patient emergencies before they happen. … https://psnet.ahrq.gov/issue/hospitals-look-computers-predict-patient-emergencies-they-happen Nuisance … https://psnet.ahrq.gov/issue/hospitals-look-computers-predict-patient-emergencies-they-happen https:/

  5. Prescribing errors in children: why they happen and how to prevent them. | PSNet

    psnet.ahrq.gov/issue/prescribing-errors-children-why-they-happen-and-how-prevent-them
    December 13, 2017 - Newspaper/Magazine Article Prescribing errors in children: why they happen and how … Prescribing errors in children: why they happen and how to prevent them. … Prescribing errors in children: why they happen and how to prevent them.

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39080/psn-pdf
    November 04, 2009 - How could this happen? November 4, 2009 Westfall SS; Mascia K. People. October 5, 2009. … https://psnet.ahrq.gov/issue/how-could-happen This story discusses an instance of mistakenly implanted … https://psnet.ahrq.gov/issue/how-could-happen

  7. Fatal PCA adverse events continue to happen...better patient monitoring is essential to prevent harm. | PSNet

    psnet.ahrq.gov/issue/fatal-pca-adverse-events-continue-happenbetter-patient-monitoring-essential-prevent-harm
    June 10, 2018 - Newspaper/Magazine Article Fatal PCA adverse events continue to happen...better patient … Citation Text: Fatal PCA adverse events continue to happen...better patient monitoring is essential … Cite Citation Citation Text: Fatal PCA adverse events continue to happen

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40815/psn-pdf
    September 28, 2011 - Program encourages reporting accidents waiting to happen: the Good Catch Awards. … https://psnet.ahrq.gov/issue/program-encourages-reporting-accidents-waiting-happen-good-catch-awards … https://psnet.ahrq.gov/issue/program-encourages-reporting-accidents-waiting-happen-good-catch-awards

  9. Learning From Defects

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/024-ss-cusp-learning-from-defects.pptx
    April 01, 2025 - Defects: Clinical or operational events or situations that you do not want to happen again Examples of … Why did it happen?  How will you reduce the likelihood of this defect from happening again?  … Program for MRSA Prevention | Surgical Services Learning From Defects 11 Question Two Why Did It Happen … MRSA Prevention | Surgical Services Learning From Defects Learning From Defects Process: Why Did It Happen … Why did it happen? How will you reduce the likelihood of this defect happening again?

  10. Action-Plan-Template (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/action-plan-template.docx
    April 01, 2022 - How will this happen? … [Be specific and include important steps to make the idea/activity happen.] _________________________ … Who will make this happen?

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47678/psn-pdf
    December 19, 2018 - When mistakes happen. December 19, 2018 Beck DL. ASH Clinical News. December 1, 2018. … https://psnet.ahrq.gov/issue/when-mistakes-happen This article provides an overview of efforts to understand … https://psnet.ahrq.gov/issue/when-mistakes-happen https://psnet.ahrq.gov/primer/patient-safety-101 https

  12. Sample “Plan-Do-Study-Act” Form | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/management/huddles-pdsa-form.html
    June 01, 2017 - Where will huddle happen? Default: In front of the visual management board       9.  … Predict what will happen when the test is carried out  (e.g., if we do “x,” “y” will happen) Measures …                 Predict what will happen … when the test is carried out (i.e., if we do “x,” “y” will happen) Measures to compare prediction

  13. Module 2: Example (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/huddles/example-pdsa-form.docx
    May 01, 2017 - Where will huddle happen? Default: In front of the visual management board 9. … Predict what will happen when the test is carried out (e.g., if we do “x,” “y” will happen) Measures … When to be done Where to be done Predict what will happen … when the test is carried out (i.e., if we do “x,” “y” will happen) Measures to compare prediction

  14. Sample “Plan-Do-Study-Act” Form | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/management/pdsa-form.html
    June 01, 2017 - reviewed during huddle; if huddle is not scheduled regularly yet, let all relevant staff know huddle will happen … Predict what will happen when the test is carried out  (e.g., if we do “x,” “y” will happen) Measures …                 Predict what will happen … when the test is carried out (i.e., if we do “x,” “y” will happen) Measures to compare prediction

  15. Plan-Do-Study-Act Worksheet (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/pdsa-worksheet.pdf
    June 02, 2025 - ______________________________________________________________________ What do you predict will happen … What do you need to do to get ready: How will you evaluate how it went: What do you predict will happen

  16. Module 2: Example (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/visual/visual-mgmt-pdsa-form.docx
    May 01, 2017 - reviewed during huddle; if huddle is not scheduled regularly yet, let all relevant staff know huddle will happen … Predict what will happen when the test is carried out (e.g., if we do “x,” “y” will happen) Measures … When to be done Where to be done Predict what will happen … when the test is carried out (i.e., if we do “x,” “y” will happen) Measures to compare prediction

  17. Learning-From-Antibiotic-Adverse (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/learning-from-antibiotic-adverse.docx
    June 01, 2021 - Events An antibiotic-associated adverse event is any event or situation that you would not want to happen … (Why did it happen?) Step 3. … (Why did it happen?) Factors Moment 1: Does the resident have symptoms that suggest an infection?

  18. Surgical errors happen, but are learners trained to recover from them? A survey of North American surgical residents and fellows. | PSNet

    psnet.ahrq.gov/issue/surgical-errors-happen-are-learners-trained-recover-them-survey-north-american-surgical
    July 28, 2021 - Study Surgical errors happen, but are learners trained to recover from them? … Surgical errors happen, but are learners trained to recover from them? … Surgical errors happen, but are learners trained to recover from them?

  19. Context is Critical: Understanding When and Why Electronic Health Record-Related Safety Hazards Happen | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/context-critical-understanding-when-and-why-electronic-health-record-related
    January 01, 2023 - Context is Critical: Understanding When and Why Electronic Health Record-Related Safety Hazards Happen … Name: Context is Critical: Understanding When and Why Electronic Health Record-Related Safety Hazards Happen … Profile: Context is Critical: Understanding When and Why Electronic Health Record-Related Safety Hazards Happen … improvements in EHR design and usability As a practicing clinician, you see themes of errors that happen … They happen over and over again and more than 99 percent of the time nothing bad happens.

  20. SOPS Medical Office Survey (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/medical-office-survey-english-2023.docx
    January 01, 2023 - SECTION A: List of Patient Safety and Quality Issues The following items describe things that can happen … In your best estimate, how often did the following things happen in your medical office OVER THE PAST … They overlook patient care mistakes that happen over and over 1 2 3 4 5 9 3. … Mistakes happen more than they should in this office 1 2 3 4 5 9 4. … This office is good at changing office processes to make sure the same problems don’t happen again
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