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Showing results for "happened".

1401. In Conversation with...James L. Reinertsen, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-withjames-l-reinertsen-md
      August 01, 2007 - The second thing that happened in many hospitals was that they had a shocking incident. … "How could that have happened here?"

1402. In Conversation With… Harlan Krumholz, MD, SM | PSNet
      psnet.ahrq.gov/perspective/conversation-harlan-krumholz-md-sm
      April 01, 2018 - We never saw them as a tool for communication or as essential to communicating what happened in the hospital … Our study showed that they cannot recount the basic facts of their condition or what happened to them

1403. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73331/psn-pdf
      May 26, 2021 - Cancer diagnoses delayed among prisoners in Washington state. May 26, 2021 Medscape Medical News. May 12, 2021. https://psnet.ahrq.gov/issue/cancer-diagnoses-delayed-among-prisoners-washington-state Delays and mistakes in health care for distinct patient populations hold improvement lessons for the broader system…

1404. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36352/psn-pdf
      April 14, 2011 - Patient expectations of fair complaint handling in hospitals: empirical data. April 14, 2011 Friele RD, Sluijs EM. Patient expectations of fair complaint handling in hospitals: empirical data. BMC Health Serv Res. 2006;6:106. https://psnet.ahrq.gov/issue/patient-expectations-fair-complaint-handling-hospitals-empir…

1405. Latent Error (or Latent Condition) | PSNet
      psnet.ahrq.gov/taxonomy/term/3488
      December 12, 2020 - Latent Error (or Latent Condition) The terms active and latent as applied to errors were coined by Reason . Latent errors (or latent conditions) refer to less apparent failures of organization or design that contributed to the occurrence of errors or allowed them to cause harm to patients. For instance, whereas …

1406. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50838/psn-pdf
      January 29, 2020 - Start the new year off right by preventing these top 10 medication errors and hazards. January 29, 2020 ISMP Medication Safety Alert! Acute care edition. January 16, 2020;26(2):1-6. https://psnet.ahrq.gov/issue/start-new-year-right-preventing-these-top-10-medication-errors-and-hazards Medication errors routinely c…

1407. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74276/psn-pdf
      January 19, 2022 - Guideline for Prevention of Unintentionally Retained Surgical Items. January 19, 2022 Croke L. Guideline for prevention of unintentionally retained surgical items. AORN J. 2021;114(6):4-6. doi:10.1002/aorn.13579. https://psnet.ahrq.gov/issue/guideline-prevention-unintentionally-retained-surgical-items Retained su…

1408. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45840/psn-pdf
      February 08, 2017 - Implementation of the safety huddle. February 8, 2017 Kylor C, Napier T, Rephann A, et al. Implementation of the Safety Huddle. Crit Care Nurse. 2016;36(6):80- 82. https://psnet.ahrq.gov/issue/implementation-safety-huddle The safety huddle is becoming common within health care practice as a way to inform clinician…

1409. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43513/psn-pdf
      September 10, 2014 - Preventing medical errors: how to proceed with caution. September 10, 2014 Shaw G. Preventing Medical Errors. The Hearing Journal. 2014;67(7). doi:10.1097/01.hj.0000452244.07451.64. https://psnet.ahrq.gov/issue/preventing-medical-errors-how-proceed-caution This article provides an overview of patient safety issues…

1410. In Conversation With… Matthew Weinger, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-matthew-weinger-md
      August 01, 2018 - Why hasn't that happened? MW : It's a function of the structure of health care.

1411. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34773/psn-pdf
      March 08, 2017 - Medication Errors: The Nursing Experience. March 8, 2017 Wolf ZR. Albany NY: Delmar Publishers; 1994. ISBN: 9780827362628. https://psnet.ahrq.gov/issue/medication-errors-nursing-experience In one of the first professional books to deal with medication error from the nursing perspective, Wolf provides a comprehensi…

1412. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34854/psn-pdf
      March 28, 2005 - Preventing lawsuits: Coalition pushes apologies and cash up-front. Dealing with medical errors when they happen-- instead of in court--can benefit doctors and patients, supporters say. March 28, 2005 Albert T. AMNews. February 7, 2005. https://psnet.ahrq.gov/issue/preventing-lawsuits-coalition-pushes-apologies-an…

1413. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36499/psn-pdf
      January 07, 2011 - Retrospective analysis of medication incidents reported using an on-line reporting system. January 7, 2011 Ashcroft DM, Cooke J. Retrospective analysis of medication incidents reported using an on-line reporting system. Pharmacy World & Science. 2006;28(6). doi:10.1007/s11096-006-9040-8. https://psnet.ahrq.gov/iss…

1414. Use of an interactive, telephone-based self-management support program to identify adverse events among ambulatory diabetes patients. | PSNet
      psnet.ahrq.gov/issue/use-interactive-telephone-based-self-management-support-program-identify-adverse-events-among
      June 11, 2010 - Study Use of an interactive, telephone-based self-management support program to identify adverse events among ambulatory diabetes patients. Citation Text: Sarkar U, Handley MA, Gupta R, et al. Use of an interactive, telephone-based self-management support program to identify adverse ev…

1415. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33613/psn-pdf
      May 01, 2005 - Organizational Change in the Face of Highly Public Errors—II. The Duke Experience May 1, 2005 Frush K. Organizational Change in the Face of Highly Public Errors—II. The Duke Experience. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-ii-duke-experience Pe…

1416. In Conversation with…Christopher P. Landrigan, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-withchristopher-p-landrigan-md
      April 01, 2005 - However, it turned out that this kind of thing happened only a handful of times over the life of the

1417. Introducing the New AHRQ WebM&M and AHRQ Patient Safety Network (PSNet) | PSNet
      psnet.ahrq.gov/perspective/introducing-new-ahrq-webmm-and-ahrq-patient-safety-network-psnet
      April 01, 2005 - However, it turned out that this kind of thing happened only a handful of times over the life of the

1418. In Conversation With… Andrew Gettinger, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-andrew-gettinger-md
      September 01, 2017 - of federal funding really changed the inflection point and pushed adoption faster than it would have happened … Thus, unforeseen events happened more frequently and were more severe than anyone predicted.( 12 ) Over

1419. Patient Safety During Hospital Discharge | PSNet
      psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge
      April 01, 2018 - We never saw them as a tool for communication or as essential to communicating what happened in the hospital … Our study showed that they cannot recount the basic facts of their condition or what happened to them

1420. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45936/psn-pdf
      March 08, 2017 - Using information from external errors to signal a "clear and present danger." March 8, 2017 ISMP Medication Safety Alert! Acute care edition. February 9, 2017;22:1-5. https://psnet.ahrq.gov/issue/using-information-external-errors-signal-clear-and-present-danger Monitoring external reports of error and harm can pr…