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Total Results: 1,692 records

Showing results for "happened".

101. In Conversation with...Albert Wu, MD, MPH | PSNet
     psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph
     February 26, 2025 - So there's no way of knowing what has happened. … And this happened after a lengthy root cause analysis, which took perhaps 100 hours to perform. … And at every meeting, the board should also track what had happened to the previous quarter's or previous … year's root cause analyses and recommendations, and again, if possible, what has happened to that kind

102. In Conversation with…Robert M. Wachter, MD | PSNet
     psnet.ahrq.gov/perspective/conversation-withrobert-m-wachter-md
     October 01, 2008 - That was appropriate when the adverse events just happened and they cost institutions more money to take … So if the hospital is going to be tagged with an adverse event that happened at another place, that's … advance directives and other elements of complex care that take time, where the metric of whether it happened … Under the old payment system, when the adverse event happened, the hospital would get paid an extra 50% … And I think that's happened.

103. 200 epidural blunders admitted after three women die. | PSNet
     psnet.ahrq.gov/issue/200-epidural-blunders-admitted-after-three-women-die
     March 18, 2020 - How could it have happened?

104. Recognizing Excellence in Diagnosis. | PSNet
     psnet.ahrq.gov/issue/recognizing-excellence-diagnosis
     November 03, 2023 - June 8, 2023 Events that inspired change: the importance of sharing what happened to

105. Learning from tragedy: the Julia Berg story. | PSNet
     psnet.ahrq.gov/issue/learning-tragedy-julia-berg-story
     October 28, 2020 - piece includes the perspectives of the patient's family and from the organization regarding what happened

106. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33670/psn-pdf
     July 01, 2008 - So there's no way of knowing what has happened. … And this happened after a lengthy root cause analysis, which took perhaps 100 hours to perform. … And at every meeting, the board should also track what had happened to the previous quarter's or previous … year's root cause analyses and recommendations, and again, if possible, what has happened to that kind

107. Patients should know who's operating, surgeons say. | PSNet
     psnet.ahrq.gov/issue/patients-should-know-whos-operating-surgeons-say
     May 15, 2024 - October 9, 2024 Inside the preventable deaths that happened within a prominent transplant

108. The fading art of the physical exam. | PSNet
     psnet.ahrq.gov/issue/fading-art-physical-exam
     July 10, 2024 - August 28, 2019 Deny, Dismiss, Dehumanise: What Happened When I Went to Hospital.

109. Resilience Engineering in Practice: a Guidebook. | PSNet
     psnet.ahrq.gov/issue/resilience-engineering-practice-guidebook
     February 06, 2019 - respond to disruptions , monitor their environment, anticipate future impacts, and learn from what happened

110. Joshua’s Story. | PSNet
     psnet.ahrq.gov/issue/joshuas-story
     February 26, 2014 - The father's quest to understand what happened led to a comprehensive inquiry that revealed regulatory

111. Canadian Incident Analysis Framework. | PSNet
     psnet.ahrq.gov/issue/canadian-incident-analysis-framework
     December 04, 2016 - gather insights from staff, patients, and family members regarding what caused the failure and why it happened

112. The Texas Health Presbyterian Hospital Ebola Crisis: A Perfect Storm of Human Errors, System Failures and Lack of Mindfulness. | PSNet
     psnet.ahrq.gov/issue/texas-health-presbyterian-hospital-ebola-crisis-perfect-storm-human-errors-system-failures
     February 23, 2018 - This analysis of the incident breaks down what happened and explores how attention to mindfulness

113. Learning from Bristol: The Report of the Public Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary 1984--1995. | PSNet
     psnet.ahrq.gov/issue/learning-bristol-report-public-inquiry-childrens-heart-surgery-bristol-royal-infirmary-1984
     October 20, 2021 - Their objectives included understanding what happened in Bristol, assessing the quality of care and system

114. Faced with a drug shortfall, doctors scramble to treat children with cancer. | PSNet
     psnet.ahrq.gov/issue/faced-drug-shortfall-doctors-scramble-treat-children-cancer
     October 30, 2019 - How could it have happened?

115. Far more could be done to stop the deadly bacteria C. diff. | PSNet
     psnet.ahrq.gov/issue/far-more-could-be-done-stop-deadly-bacteria-c-diff
     November 08, 2023 - It happened to me, as a pregnant OB-GYN.

116. Uncovering the shocking dangers of misdiagnosis. | PSNet
     psnet.ahrq.gov/issue/uncovering-shocking-dangers-misdiagnosis
     May 13, 2020 - March 13, 2024 What Happened to Patient Safety.

117. COVID-19 leads to increased need for dialysis machines. | PSNet
     psnet.ahrq.gov/issue/covid-19-leads-increased-need-dialysis-machines
     April 29, 2020 - July 10, 2024 Inside the preventable deaths that happened within a prominent transplant

118. When a heart attack goes undiagnosed. | PSNet
     psnet.ahrq.gov/issue/when-heart-attack-goes-undiagnosed
     November 08, 2023 - It happened to me, as a pregnant OB-GYN.

119. Saving Moms. | PSNet
     psnet.ahrq.gov/issue/saving-moms
     April 26, 2023 - It happened to me, as a pregnant OB-GYN.

120. Building Capacity for Patient Safety | PSNet
     psnet.ahrq.gov/perspective/building-capacity-patient-safety
     July 31, 2023 - Based on that event, we were able to alert healthcare workers about what happened to bring attention … You need a feedback loop built into the system to share what happened and what the organization is doing … Being able to take what happened and share those stories across different settings is helpful. … We receive 300,000 reports a year but do not often get information on why something happened or how it … happened.