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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/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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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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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/node/47861/psn-pdf
April 24, 2019 - Laney's story: the problem of delayed diagnosis of
pediatric stroke.
April 24, 2019
Fitzsimons BT, Fitzsimons LL, Sun LR. Laney's Story: The Problem of Delayed Diagnosis of Pediatric
Stroke. Pediatrics. 2019;143(4):e20183458. doi:10.1542/peds.2018-3458.
https://psnet.ahrq.gov/issue/laneys-story-problem-delayed-dia…
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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
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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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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/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 …
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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,
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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,
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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
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/fecal-incontinence_consumer.pdf
July 01, 2016 - to the sphincter muscles or to the nerves that control
the rectum and sphincter muscles
» This can happen … � Loss of stretch or stiffening of the rectum
» This can happen from surgery involving the rectum
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psnet.ahrq.gov/issue/healthcare-industry-representatives-maximizing-benefits-and-reducing-risks
March 18, 2010 - December 16, 2014
Program encourages reporting accidents waiting to happen: the Good
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module6/module6-care-for-caregiver.pptx
May 01, 2011 - The second-victim is often fearful at this point about what is going to happen next and whether or not … clinical staff involved in the event, notify clinical staff involved in the event what is going to happen
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psnet.ahrq.gov/issue/doctors-diagnosing-gets-technological-boost
May 18, 2005 - August 21, 2019
Hospitals look to computers to predict patient emergencies before they happen
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psnet.ahrq.gov/issue/what-happens-between-visits-adverse-and-potential-adverse-events-among-low-income-urban
February 22, 2011 - Study
What happens between visits? Adverse and potential adverse events among a low-income, urban, ambulatory population with diabetes.
Citation Text:
Sarkar U, Handley MA, Gupta R, et al. What happens between visits? Adverse and potential adverse events among a low-income, urban, ambu…
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psnet.ahrq.gov/node/33841/psn-pdf
September 01, 2017 - which get loaded into the medication side effect dictionaries because the threshold is "this could happen … When you ask people why they don't just turn off those "this could happen" alerts, there's a concern
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psnet.ahrq.gov/node/33801/psn-pdf
February 01, 2016 - When computers entered your world, is it something you thought
would happen or were you optimistic and … perspective/conversation-withchristine-sinsky-md
RW: It may not be obvious to everyone why that would happen … How can I make that happen?