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Total Results: 1,692 records

Showing results for "happened".

1421. Spotlight Case (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.127_slideshow.ppt
      May 01, 2006 - Spotlight Case Spotlight Case May 2006 Right? Left? Neither! Source and Credits This presentation is based on the May 2006 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Elizabeth A. Howell, MD, MPP; Mark R. Chassin, MD…

1422. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867655/psn-pdf
      February 26, 2025 - Learning Health Systems for Patient Safety February 26, 2025 Savitz LA, Sousane Z, Mossburg SE. Learning Health Systems for Patient Safety. PSNet [internet]. 2025. https://psnet.ahrq.gov/perspective/learning-health-systems-patient-safety Despite an observable decrease in adverse events in health care over time, rat…

1423. Measuring Patient Safety | PSNet
      psnet.ahrq.gov/perspective/measuring-patient-safety
      December 14, 2022 - Measuring Patient Safety Michelle Schreiber, MD; Cindy Van, MHSA; Sarah E. Mossburg, RN, PhD | December 14, 2022  Also Read the Conversation View more articles from the same authors. Citation Text: Schreiber M, Van C, Mossburg SE. Measuring Patient Safety. PSN…

1424. Second victims among baccalaureate nursing students in the aftermath of a patient safety incident: an exploratory cross-sectional study. | PSNet
      psnet.ahrq.gov/issue/second-victims-among-baccalaureate-nursing-students-aftermath-patient-safety-incident
      June 09, 2021 - Study Second victims among baccalaureate nursing students in the aftermath of a patient safety incident: an exploratory cross-sectional study. Citation Text: Van Slambrouck L, Verschueren R, Seys D, et al. Second victims among baccalaureate nursing students in the aftermath of a patient …

1425. "It's a big part of being good surgeons": surgical trainees' perceptions of error recovery in the operating room. | PSNet
      psnet.ahrq.gov/issue/its-big-part-being-good-surgeons-surgical-trainees-perceptions-error-recovery-operating-room
      August 26, 2020 - Study "It's a big part of being good surgeons": surgical trainees' perceptions of error recovery in the operating room. Citation Text: Gabrysz-Forget F, Zahabi S, Young M, et al. "It's a big part of being good surgeons": surgical trainees' perceptions of error recovery in the operating r…

1426. Operating at night does not increase the risk of intraoperative adverse events. | PSNet
      psnet.ahrq.gov/issue/operating-night-does-not-increase-risk-intraoperative-adverse-events
      July 01, 2017 - Study Operating at night does not increase the risk of intraoperative adverse events. Citation Text: Eskesen TG, Peponis T, Saillant N, et al. Operating at night does not increase the risk of intraoperative adverse events. Am J Surg. 2018;216(1):19-24. doi:10.1016/j.amjsurg.2017.10.026. …

1427. 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

1428. 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

1429. In Conversation With... Michael L. Millenson | PSNet
      psnet.ahrq.gov/perspective/conversation-michael-l-millenson
      April 27, 2022 - tracking the last year of medical data on my wearable device (or implanted device), and I can show what happened

1430. The Media’s Role in Patient Safety | PSNet
      psnet.ahrq.gov/perspective/medias-role-patient-safety
      April 27, 2022 - tracking the last year of medical data on my wearable device (or implanted device), and I can show what happened

1431. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34008/psn-pdf
      March 17, 2011 - Sorry Works! March 17, 2011 https://psnet.ahrq.gov/issue/sorry-works Sorry Works! supports a full-disclosure approach to medical errors. They encourage doctors and their insurers to be honest when mistakes happen, offer apologies, and provide compensation up-front to patients and their attorneys to minimize litiga…

1432. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73542/psn-pdf
      July 28, 2021 - Diagnostic safety event reporting. July 28, 2021 Carr S. ImproveDx. July 2021;8(4). https://psnet.ahrq.gov/issue/diagnostic-safety-event-reporting Adverse event reporting can clarify when mistakes happen and what reduction strategies to apply. This article describes existing efforts to examine diagnostic error thr…

1433. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33879/psn-pdf
      May 01, 2019 - In Conversation With… Jane Brice, MD, MPH May 1, 2019 In Conversation With… Jane Brice, MD, MPH. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-jane-brice-md-mph Editor's note: Dr. Brice is Professor and Chair of the Department of Emergency Medicine at the University of North Carolina. She…

1434. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36219/psn-pdf
      October 18, 2010 - Risk, society and system failure. October 18, 2010 Scalliet P. Risk, society and system failure. Radiotherapy and Oncology. 2006;80(3). doi:10.1016/j.radonc.2006.07.003. https://psnet.ahrq.gov/issue/risk-society-and-system-failure The author discusses why large scale accidents happen and how to manage risk in radi…

1435. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35779/psn-pdf
      July 20, 2010 - Our story. July 20, 2010 King S. Our story. Pediatr Radiol. 2006;36(4):284-6. https://psnet.ahrq.gov/issue/our-story The author tells the story of medical errors that led to the death of her daughter Josie in 2001 and discusses the activities her family has undertaken to prevent similar incidents from happening to…

1436. 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…

1437. 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…

1438. 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…

1439. How Does Health Care Simulation Affect Patient Care? | PSNet
      psnet.ahrq.gov/perspective/how-does-health-care-simulation-affect-patient-care
      August 01, 2018 - Why hasn't that happened? MW : It's a function of the structure of health care.

1440. 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…