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psnet.ahrq.gov/node/50392/psn-pdf
September 01, 2019 - I remember Ken Kizer announcing these eight things that should never happen in health care
and they … The
notion that some things should not happen, that we should have a high degree of accuracy around, … "This
should always happen"; "this should never happen."
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psnet.ahrq.gov/issue/patient-safety-0
February 28, 2015 - February 13, 2013
Program encourages reporting accidents waiting to happen: the Good
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digital.ahrq.gov/ahrq-funded-projects/past-initiatives/privacy-and-security-project/illinois
January 01, 2023 - This can only happen through the widespread adoption of health information technology and information
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psnet.ahrq.gov/node/842919/psn-pdf
February 01, 2023 - of basal and/or nutritional insulin in a patient with type 1 diabetes is an event that should never happen … Ask what will happen with your medicines.
3. Know what will happen with your diet.
4. … Find out what will happen when you go home.
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psnet.ahrq.gov/issue/preventing-medication-errors-during-codes
February 22, 2023 - Related Resources
Hospitals look to computers to predict patient emergencies before they happen
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/webinar-012220-fry.pdf
June 02, 2025 - Understanding CAHPS® Surveys: A Primer for New Users - Fry
WHAT IS PATIENT EXPERIENCE
AND HOW DOES CAHPS
MEASURE IT?
Stephanie Fry
Senior Study Director
Westat
What is Patient Experience?
Patient experience encompasses the range of interactions that
patients have with the health care system, including:
Co…
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psnet.ahrq.gov/node/33863/psn-pdf
August 01, 2018 - You can
imagine 1 week in 5 for circumstances that virtually never happen. … I imagine
that some of it they're training over and over again for things that essentially never happen … someone is saying "push a drug," then there has to be someone behind the curtain
showing what would happen
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psnet.ahrq.gov/web-mm/duty-disclose-someone-elses-error
June 01, 2004 - Angry and upset, the parents asked repeatedly, "How could this happen? … another health care worker's error can help ensure that these challenging but important conversations happen
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psnet.ahrq.gov/issue/intraoperative-adverse-events-abdominal-surgery-what-happens-operating-room-does-not-stay
January 23, 2017 - Study
Intraoperative adverse events in abdominal surgery: what happens in the operating room does not stay in the operating room.
Citation Text:
Bohnen JD, Mavros MN, Ramly EP, et al. Intraoperative Adverse Events in Abdominal Surgery: What Happens in the Operating Room Does Not Stay in …
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psnet.ahrq.gov/issue/exploring-clinical-lessons-learned-experienced-hospitalists-diagnostic-errors-and-successes
January 15, 2025 - Study
Exploring clinical lessons learned by experienced hospitalists from diagnostic errors and successes.
Citation Text:
Kotwal S, Howell M, Zwaan L, et al. Exploring clinical lessons learned by experienced hospitalists from diagnostic errors and successes. J Gen Intern Med. 2024;39(8):…
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digital.ahrq.gov/sites/default/files/docs/workflowtoolkit/IFQHC_workflow_assessment.pdf
January 01, 2007 - Workflow Assessment
Workflow Assessment
Clinic name:
Individuals interviewed:
Assessors:
Assessment date:
Front Desk
How are appointments made?
What are the steps for each type?
Phone in advance
Phone for same day appointment
Previous visit…
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psnet.ahrq.gov/perspective/role-patient-improving-patient-safety
March 01, 2007 - lawyer at Hopkins, and said, "What happened to Josie, that little strike of lightning, that doesn't happen … These systems are eventually going to break down and something is going to happen that wasn't that doctor's … But something bad is going to happen and it's going to look like it's that person's fault or that person
-
psnet.ahrq.gov/node/33679/psn-pdf
January 01, 2009 - Thus, these data do not necessarily speak to what will happen to liability if a physician's disclosure … We are going to do what it takes to make you better and make
sure the same thing does not happen again
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hcup-us.ahrq.gov/datainnovations/raceethnicitytoolkit/nm25.pdf
June 16, 2014 - We
want to make sure that this does not happen in New Mexico.
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mod2concl.html
October 01, 2014 - Module 2: Communicating Change in a Resident's Condition
Conclusion
Previous Page Next Page
Table of Contents
Module 2: Communicating Change in a Resident's Condition
Learning and Performance Objectives
Session 1
Session 2
Conclusion
Additional Tools and Resources
Appendix. Example of th…
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/DESC-technique.pdf
June 01, 2021 - DESC Technique for Conflict With Residents and Families
DESC Script. Johns Hopkins Medicine, Armstrong Institute. Kentucky
Hospital Improvement Innovation Network. KY. July 2012.
http://www.k-
hen.com/Portals/16/Documents/PSCTCommunicationsLab.pdf.
Accessed Jun 19, 2017.
Describe the specific situation.
Expre…
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psnet.ahrq.gov/perspective/new-insights-safety-and-health-it
August 01, 2015 - 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. … You may see a doctor periodically, but most of your care will happen at your home or your workplace,
-
psnet.ahrq.gov/perspective/conversation-robert-m-wachter-md
August 01, 2015 - 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. … You may see a doctor periodically, but most of your care will happen at your home or your workplace,
-
psnet.ahrq.gov/issue/20-years-after-err-human-bibliometric-analysis-iom-reports-impact-research-patient-safety
July 15, 2020 - Review
20 years after To Err Is Human: a bibliometric analysis of ‘the IOM report’s’ impact on research on patient safety.
Citation Text:
St.Pierre M, Grawe P, Bergström J, et al. 20 years after To Err Is Human: a bibliometric analysis of ‘the IOM report’s’ impact on research on patient …
-
psnet.ahrq.gov/node/33611/psn-pdf
July 01, 2005 - To make the study happen, all we
needed was one additional intern for half a year, during the intervention … this is something that we
need to address and let's see what we can do to make these kinds of changes happen