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psnet.ahrq.gov/issue/after-roe-challenges-provision-lifesaving-care
September 23, 2015 - It happened to me, as a pregnant OB-GYN.
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psnet.ahrq.gov/issue/disclosure-through-our-eyes
July 02, 2009 - June 26, 2019
Deny, Dismiss, Dehumanise: What Happened When I Went to Hospital.
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psnet.ahrq.gov/issue/perchance-think
December 08, 2016 - April 10, 2019
WebM&M Cases
What Happened on Telemetry
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psnet.ahrq.gov/issue/top-penn-state-health-surgeon-warned-leaders-about-transplant-problems-months-shutdown-then
July 18, 2018 - September 20, 2023
Inside the preventable deaths that happened within a prominent transplant
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psnet.ahrq.gov/issue/simulation-based-trial-surgical-crisis-checklists
July 25, 2011 - available, and 97% of participants reported that they would want the checklist used if one of these crises happened
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psnet.ahrq.gov/sites/default/files/2024-07/spotlight_case_intraoperative_awareness_during_rhinoplasty_slides_final.pptx
January 01, 2024 - and embarrassed that the patient remembered waking up during the operation but could not explain what happened … Details of what is recalled should be elicited and compared with what happened during the operation. … It is therefore very important to review the anesthetic record to understand what happened.
19
19 … It will be obvious if the patient truly remembers things that happened during the procedure.
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psnet.ahrq.gov/web-mm/intraoperative-awareness-during-rhinoplasty
January 29, 2021 - and embarrassed that the patient remembered waking up during the operation but could not explain what happened … Details of what is recalled should be elicited and compared with what happened during the operation. … It is therefore very important to review the anesthetic record to understand what happened. … It will be obvious if the patient truly remembers things that happened during the procedure.
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psnet.ahrq.gov/issue/associations-between-hospitalist-shift-busyness-diagnostic-confidence-and-resource
September 16, 2020 - October 13, 2018
View More
Related Resources
“I had no idea this happened
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psnet.ahrq.gov/issue/teaching-about-diagnostic-errors-through-virtual-patient-cases-pilot-exploration
September 18, 2013 - January 23, 2017
What happened to my patient?
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psnet.ahrq.gov/issue/do-some-surgical-implants-do-more-harm-good
January 14, 2011 - View More
Related Resources
Inside the preventable deaths that happened
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psnet.ahrq.gov/issue/weekend-versus-weekday-admission-and-mortality-myocardial-infarction
February 18, 2011 - More
Related Resources
WebM&M Cases
What Happened
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psnet.ahrq.gov/issue/errors-otolaryngology-revisited
August 11, 2010 - May 17, 2023
Events that inspired change: the importance of sharing what happened to
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psnet.ahrq.gov/issue/covid-19-delaying-routine-care-chronic-disease-startups-brace-slew-complications
May 02, 2018 - It happened to me, as a pregnant OB-GYN.
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psnet.ahrq.gov/node/33635/psn-pdf
July 01, 2006 - AF: You want to state what has happened, but you don't want to conjecture until you gain the information … I
think it's reasonable to say what happened, and then to be sure that the people fielding these issues … to the
public are skilled enough to say, "I can tell you that this is what has happened, and I can … We described
what happened.
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psnet.ahrq.gov/issue/swarming-improve-patient-care-novel-approach-root-cause-analysis
September 23, 2020 - The process begins with a preliminary investigation into what happened and who was involved, followed
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psnet.ahrq.gov/perspective/conversation-michael-cohen-rph-ms-scd-hon-0
October 24, 2021 - We thought for sure that many errors that might have happened in the past wouldn't happen. … conversation between the pharmacist and the patient, a lot of errors that we saw in the past would not have happened … If you go to our website, it's very easy—just tell us what happened. … When I need reports regarding how many of this happened, they do that for me.
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psnet.ahrq.gov/issue/gender-biases-and-diagnostic-delay-inflammatory-bowel-disease-multicenter-observational-study
March 09, 2022 - It happened to me, as a pregnant OB-GYN.
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psnet.ahrq.gov/issue/using-name-overlap-analysis-understand-medication-name-search-safety
August 31, 2022 - project
October 16, 2019
Events that inspired change: the importance of sharing what happened
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psnet.ahrq.gov/issue/future-artificial-intelligence-applications-cancer-care-global-cross-sectional-survey
April 27, 2022 - May 20, 2020
Deny, Dismiss, Dehumanise: What Happened When I Went to Hospital.
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psnet.ahrq.gov/issue/when-lights-go-down-delivery-room-lessons-ransomware-attack
September 02, 2020 - It happened to me, as a pregnant OB-GYN.