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psnet.ahrq.gov/issue/doctors-must-stop-tuning-out-black-women-it-happened-me-pregnant-ob-gyn
June 24, 2020 - It happened to me, as a pregnant OB-GYN. … It happened to me, as a pregnant OB-GYN. Gillispie-Bell V. USA Today. April 14, 2023. … It happened to me, as a pregnant OB-GYN. Gillispie-Bell V. USA Today. April 14, 2023.
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psnet.ahrq.gov/issue/drug-error-eskenazi-hospital-killed-prominent-cancer-researcher-heres-how-it-happened
September 09, 2015 - Here's how it happened. … Here's how it happened. Evans T. Indianapolis Star. October 30, 2020. … Here's how it happened. Evans T. Indianapolis Star. October 30, 2020.
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psnet.ahrq.gov/node/847060/psn-pdf
January 01, 2001 - The Emperor’s New Clothes: Or Whatever Happened To
“Human Error”? … https://psnet.ahrq.gov/issue/emperors-new-clothes-or-whatever-happened-human-error
This thought piece … https://psnet.ahrq.gov/issue/emperors-new-clothes-or-whatever-happened-human-error
https://psnet.ahrq.gov
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psnet.ahrq.gov/issue/when-mistakes-happen
May 13, 2020 - Newspaper/Magazine Article
When mistakes happen.
Citation Text:
When mistakes happen. Beck DL. ASH Clinical News. December 1, 2018.
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psnet.ahrq.gov/node/853240/psn-pdf
September 06, 2023 - Debriefing after significant clinical events helps affected staff develop a shared mental model of what
happened … , why it happened, and how it can be prevented in the future.
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psnet.ahrq.gov/node/33678/psn-pdf
January 01, 2009 - You just
went and told the patient what happened. … They protect the words, "I'm sorry," but they don't
protect the statement about what happened. … Here's what we know about what happened, and what we've done to mitigate its impact on you. … I
think an expression of regret about what happened at that point is also appropriate. … But that follow-up conversation usually is an opportunity to again explain what happened.
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psnet.ahrq.gov/web-mm/hidden-heparins-hit-happens
March 27, 2024 - SPOTLIGHT CASE
Hidden Heparins: HIT Happens
Citation Text:
Fogarty PF. Hidden Heparins: HIT Happens. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/node/867653/psn-pdf
February 26, 2025 - They happened behind closed doors, and we did not talk about them much. … They saw that a group of people got together to discuss what
happened, but then frontline staff would … not know what happened after that. … There are three basic
questions we use all the time: “What happened?” “Why did it happen?” … In RCA2,
we use the Five Whys to ask why this event happened and create causal chains.
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psnet.ahrq.gov/issue/seeking-answers-hearing-silence
October 09, 2024 - whose daughter died from medical error and the resistance she faced when trying to understand what happened … July 5, 2023
Deny, Dismiss, Dehumanise: What Happened When I Went to Hospital.
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psnet.ahrq.gov/node/33878/psn-pdf
April 01, 2019 - But that's not what has happened. There are now many
lawyers who specialize in ACC law. … error and this happened to you." … So say, "My bad that this happened." … She expressed how terrible she felt about what had happened. … He said to his mother, I'm really upset by what happened to my sister.
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psnet.ahrq.gov/issue/how-could-happen
September 19, 2007 - Newspaper/Magazine Article
How could this happen?
Citation Text:
How could this happen? Westfall SS; Mascia K. People. October 5, 2009.
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psnet.ahrq.gov/issue/when-incidents-happen
January 14, 2011 - Commentary
When incidents happen.
Citation Text:
Newfield JS. When Incidents Happen. Home Health Care Manag Pract. 2006;18(5). doi:10.1177/1084822306287998.
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…
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psnet.ahrq.gov/perspective/conversation-jennifer-schulz-moore-llb-ma-phd
February 26, 2025 - But that's not what has happened. There are now many lawyers who specialize in ACC law. … error and this happened to you." … So say, "My bad that this happened." … She expressed how terrible she felt about what had happened. … He said to his mother, I'm really upset by what happened to my sister.
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psnet.ahrq.gov/issue/videos-simulated-after-action-reviews-training-resource-support-social-and-inclusive-learning
May 22, 2024 - Debriefing after significant clinical events helps affected staff develop a shared mental model of what happened … , why it happened, and how it can be prevented in the future.
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psnet.ahrq.gov/issue/wrong-goodbye
October 05, 2022 - How could it have happened? … How could it have happened?
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psnet.ahrq.gov/issue/minnesota-lets-nurses-practice-while-disciplinary-investigations-drag-patients-keep-getting
April 22, 2020 - August 23, 2023
Inside the preventable deaths that happened within a prominent transplant … View More
Related Resources
Inside the preventable deaths that happened
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psnet.ahrq.gov/issue/sued-misdiagnosis-it-could-happen-you
February 07, 2024 - Commentary
Sued for misdiagnosis? It could happen to you.
Citation Text:
Lippman H, Davenport J. Sued for misdiagnosis? It could happen to you. J Fam Pract. 2010;59(9):498-508.
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psnet.ahrq.gov/perspective/disclosure-medical-error
January 01, 2009 - You just went and told the patient what happened. … They protect the words, "I'm sorry," but they don't protect the statement about what happened. … Here's what we know about what happened, and what we've done to mitigate its impact on you. … I think an expression of regret about what happened at that point is also appropriate. … But that follow-up conversation usually is an opportunity to again explain what happened.
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psnet.ahrq.gov/perspective/conversation-withthomas-h-gallagher-md
January 01, 2009 - You just went and told the patient what happened. … They protect the words, "I'm sorry," but they don't protect the statement about what happened. … Here's what we know about what happened, and what we've done to mitigate its impact on you. … I think an expression of regret about what happened at that point is also appropriate. … But that follow-up conversation usually is an opportunity to again explain what happened.
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psnet.ahrq.gov/issue/unstoppable-doctor-has-been-investigated-every-level-government-how-he-still-practicing
September 16, 2020 - December 20, 2023
Inside the preventable deaths that happened within a prominent transplant … September 20, 2023
Inside the preventable deaths that happened within a prominent transplant