U.S. flag

An official website of the Department of Health & Human Services

AHRQ: Agency for Healthcare Research and Quality

Search AHRQ

For an exact phrase match, enclose search terms in double quotes.

Go to Advanced Search
Go to Basic Search

Results

Total Results: 1,692 records

Showing results for "happened".

  1. 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…

  2. 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…

  3. 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…

  4. 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…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853902/psn-pdf
    September 27, 2023 - It is not entirely clear what happened, but aggressive diuresis with concurrent diarrhea, possibly in

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865429/psn-pdf
    April 24, 2024 - Precipitating factors include direct irritation of atrial tissue by the venous cannula (as appears to have happened

  7. Ensuring Patient and Workforce Safety Culture in Healthcare | PSNet

    psnet.ahrq.gov/perspective/ensuring-patient-and-workforce-safety-culture-healthcare
    March 27, 2024 - most commonly sought form of support was a respected peer with whom to discuss the details of what happened

  8. A Missed Bowel Perforation - the Importance of Diagnostic Reasoning | PSNet

    psnet.ahrq.gov/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning
    January 29, 2021 - It is not entirely clear what happened, but aggressive diuresis with concurrent diarrhea, possibly in

  9. "Do You Want Everything Done?": Clarifying Code Status | PSNet

    psnet.ahrq.gov/web-mm/do-you-want-everything-done-clarifying-code-status
    March 27, 2024 - possible that fatigue and burnout contributed to the resident’s failure to enter the orders promptly as happened

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865454/psn-pdf
    March 27, 2024 - most commonly sought form of support was a respected peer with whom to discuss the details of what happened

  11. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery | PSNet

    psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery
    March 25, 2020 - Precipitating factors include direct irritation of atrial tissue by the venous cannula (as appears to have happened

  12. 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…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49424/psn-pdf
    November 01, 2003 - Waiting Too Long November 1, 2003 Rosen MA. Waiting Too Long. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/waiting-too-long The Case A 31-year-old gravida 1, para 1 woman presented at 40 weeks in the early stages of labor having received limited prenatal care at an outside clinic. Physical exam performed…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33633/psn-pdf
    May 01, 2006 - Patient Safety in the Physician Office Setting May 1, 2006 Elder NC. Patient Safety in the Physician Office Setting. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/patient-safety-physician-office-setting Perspective Dr. Jones was sure he had increased Mr. H's cholesterol-lowering medication to 80 mg 6 …

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33705/psn-pdf
    January 01, 2011 - Risk Management and Patient Safety December 1, 2010 Manuel BM, McCarthy JL, Berry WR, et al. Risk Management and Patient Safety. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/risk-management-and-patient-safety Perspective In 1990, a Harvard-based research team reported the incidence of medical errors …

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49851/psn-pdf
    January 01, 2019 - One Bronchoscopy, Two Errors January 1, 2019 Leiten E, Nielsen R. One Bronchoscopy, Two Errors. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors The Case A 67-year-old man with a history of hypertension was admitted to the intensive care unit (ICU) with hypoxic respiratory failure…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33694/psn-pdf
    April 01, 2010 - In Conversation with…Janet Corrigan, PhD, MBA April 1, 2010 In Conversation with…Janet Corrigan, PhD, MBA. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/conversation-withjanet-corrigan-phd-mba Editor's note: Janet M. Corrigan, PhD, MBA, is president and CEO of the National Quality Forum (NQF), a priva…

  18. 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…

  19. 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.

  20. 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…
SHARE:
Facebook Twitter Print Facebook Share

Similar Terms:

Search the AHRQ Archive

Information and reports more than 5 years old may be found in the AHRQ Archive site.

Search Archive

Search Within A Specific AHRQ Site

You selected to view results for the following site:

View results from all sites