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Showing results for "happened".

121. In Conversation with... Regina Hoffman about Building Capacity for Patient Safety | PSNet
     psnet.ahrq.gov/perspective/conversation-regina-hoffman-about-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.

122. In Conversation With… Timothy B. McDonald, MD, JD | PSNet
     psnet.ahrq.gov/perspective/conversation-timothy-b-mcdonald-md-jd
     February 26, 2025 - They were allowed to call a hotline number and report issues that had happened. … That is how physicians became engaged in notifying the organization about things that had happened. … about 16% of them will say anything empathically, anything along the lines of "I'm so sorry this has happened … You don't know the facts yet, but you do know something terrible has happened to her."

123. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33688/psn-pdf
     October 01, 2009 - A couple of things happened in the summer of 2003 that caused us to focus on King/Drew. … RW: You mentioned that there was a second thing that happened? … Then, not only is the problem what actually happened, but the problem is that you tried to cover it … mistake was made, patients may have died, and the key thing is to be honest about it, explain how it happened … RW: If a hospital that had the same deficiencies and the same Joint Commissioner or state reports happened

124. Strengthening open disclosure in maternity services in the English NHS: the DISCERN realist evaluation study. | PSNet
     psnet.ahrq.gov/issue/strengthening-open-disclosure-maternity-services-english-nhs-discern-realist-evaluation-study
     April 12, 2023 - Following adverse events, many patients and families welcome disclosure from their providers about what happened

125. Safety II behavior in a pediatric intensive care unit. | PSNet
     psnet.ahrq.gov/issue/safety-ii-behavior-pediatric-intensive-care-unit
     January 12, 2022 - frequently referred to as Safety-I , involved responding to adverse events and near misses after they happened

126. Identifying Adverse Events Not Present on Admission: Can We Do It? | PSNet
     psnet.ahrq.gov/perspective/identifying-adverse-events-not-present-admission-can-we-do-it
     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.

127. Every error a treasure: improving medication use with a nonpunitive reporting system. | PSNet
     psnet.ahrq.gov/issue/every-error-treasure-improving-medication-use-nonpunitive-reporting-system
     August 17, 2016 - describe the implementation of a nonpunitive reporting system at their hospital and the improvements that happened

128. The glaring loophole in U.S. virus response: human error. | PSNet
     psnet.ahrq.gov/issue/glaring-loophole-us-virus-response-human-error
     March 18, 2020 - View More Related Resources Inside the preventable deaths that happened

129. Use systems redesign and the law to prevent medical errors and accidents. | PSNet
     psnet.ahrq.gov/issue/use-systems-redesign-and-law-prevent-medical-errors-and-accidents
     August 26, 2020 - July 19, 2023 Inside the preventable deaths that happened within a prominent transplant

130. Doctors wrestle with A.I. in patient care, citing lax oversight. | PSNet
     psnet.ahrq.gov/issue/doctors-wrestle-ai-patient-care-citing-lax-oversight
     August 09, 2023 - How could it have happened?

131. The APSF: 20-year anniversary of the first patient safety organization: past, present & future. | PSNet
     psnet.ahrq.gov/issue/apsf-20-year-anniversary-first-patient-safety-organization-past-present-future
     October 26, 2022 - Here's how it happened.

132. The pain was unbearable. So why did doctors turn her away? | PSNet
     psnet.ahrq.gov/issue/pain-was-unbearable-so-why-did-doctors-turn-her-away
     November 25, 2020 - Here's how it happened.

133. The wrong foot, and other tales of surgical error. | PSNet
     psnet.ahrq.gov/issue/wrong-foot-and-other-tales-surgical-error
     January 18, 2023 - How could it have happened?

134. Phony diagnoses hide high rates of drugging at nursing homes. | PSNet
     psnet.ahrq.gov/issue/phony-diagnoses-hide-high-rates-drugging-nursing-homes
     December 22, 2021 - How could it have happened?

135. Antifatness in the surgical setting. | PSNet
     psnet.ahrq.gov/issue/antifatness-surgical-setting
     October 12, 2022 - Equity in Patient Safety March 27, 2024 Inside the preventable deaths that happened

136. Doctors were alarmed: would I have my children have surgery here? | PSNet
     psnet.ahrq.gov/issue/doctors-were-alarmed-would-i-have-my-children-have-surgery-here
     February 19, 2020 - How could it have happened?

137. Debriefing for Clinical Learning | PSNet
     psnet.ahrq.gov/primer/debriefing-clinical-learning
     September 15, 2024 - When a person asks, “What happened?” they are initiating the process of debriefing. … What happened last night? Nurse JA is the clinical nurse supervisor on a trauma unit. … JA has a list of personnel who were present and wants to find out what happened, why it happened, and

138. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33594/psn-pdf
     November 18, 2021 - When a person asks, “What happened?” they are initiating the process of debriefing. … What happened last night? Nurse JA is the clinical nurse supervisor on a trauma unit. … psnet.ahrq.gov/primer/root-cause-analysis has a list of personnel who were present and wants to find out what happened … , why it happened, and how to prevent a similar event from happening ever again.

139. Incident Reporting: More Attention to the Safety Action Feedback Loop, Please | PSNet
     psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please
     September 01, 2011 - you wouldn't want to do the whole aviation style, let's get the black box and find out exactly what happened … Because otherwise, you'll never really find out what happened and any resulting root cause analysis will … We know that it's very difficult to track down what's happened if weeks to months have gone by. … , and if you can identify them 6 months later, they're probably not going to remember a lot of what happened … They just want to let somebody know that something important happened, and if somebody in a position

140. In Conversation With…Kaveh G. Shojania, MD | PSNet
     psnet.ahrq.gov/perspective/conversation-withkaveh-g-shojania-md
     September 01, 2011 - you wouldn't want to do the whole aviation style, let's get the black box and find out exactly what happened … Because otherwise, you'll never really find out what happened and any resulting root cause analysis will … We know that it's very difficult to track down what's happened if weeks to months have gone by. … , and if you can identify them 6 months later, they're probably not going to remember a lot of what happened … They just want to let somebody know that something important happened, and if somebody in a position