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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/impact-patient-safety-bundle-and-team-based-training-obstetric-hypertensive-emergencies
July 21, 2021 - It happened to me, as a pregnant OB-GYN.
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psnet.ahrq.gov/issue/identifying-and-classifying-diagnostic-errors-acute-care-across-hospitals-early-lessons
April 12, 2023 - May 19, 2021
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Related Resources
“I had no idea this happened
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psnet.ahrq.gov/issue/stigmatizing-language-patient-demographics-and-errors-diagnostic-process
April 12, 2023 - April 24, 2018
View More
Related Resources
“I had no idea this happened
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psnet.ahrq.gov/issue/diagnostic-disparities-and-strategies-enhancing-diagnostic-equity-hospital-medicine
April 12, 2023 - October 13, 2018
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Related Resources
“I had no idea this happened
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psnet.ahrq.gov/issue/morbidity-and-mortality-caused-noncompliance-california-hospital-licensure-immediate
May 19, 2021 - January 9, 2024
Inside the preventable deaths that happened within a prominent transplant
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psnet.ahrq.gov/issue/investigating-mediating-effect-patient-self-efficacy-relationship-between-patient-safety
September 08, 2021 - September 14, 2022
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What Happened to
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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/examination-leapfrog-safety-measures-and-magnet-designation
January 27, 2021 - May 17, 2023
Events that inspired change: the importance of sharing what happened to
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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.
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psnet.ahrq.gov/node/33820/psn-pdf
December 01, 2016 - The way I would look at it is to try to understand what happened, why did it
happen, and what do you … JB: W cubed: What happened? Why did it happen? What are we going to do to prevent it in the future? … management have the courage to look a reporter in the eye
and say, "First we need to understand what happened
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psnet.ahrq.gov/node/49603/psn-pdf
June 01, 2010 - Finally, look at how often (and under
what circumstances) this or something similar has happened, either … It is about telling stories of what happened.
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psnet.ahrq.gov/perspective/conversation-jose-morfin-md-fasn
April 28, 2021 - If there has been an infection, they will use that visit to go back and work out what happened, as the … When you go back and say, “well, what happened here,” it acts as another safeguard and allows us to identify … When a PD patient gets peritonitis, nearly every time you can trace back and figure out what happened … That is some of the troubleshooting and evaluation we do to try to figure out what could have happened … What has happened, as I referenced before, is that the advent of Bluetooth technology has lessened the
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psnet.ahrq.gov/node/866370/psn-pdf
July 31, 2024 - 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/node/841305/psn-pdf
January 27, 2023 - Medical records are viewed as
the truth of what happened to a patient. … from the learners themselves and to help the
learners come to their own guided understanding of what happened
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psnet.ahrq.gov/issue/attitudes-and-practices-related-clinical-alarms
April 18, 2018 - January 18, 2012
WebM&M Cases
What Happened on Telemetry
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psnet.ahrq.gov/issue/structural-iatrogenesis-43-year-old-man-opioid-misuse
September 04, 2016 - March 1, 2023
Medication mix-up: what happened at Vanderbilt and how it impacts health
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psnet.ahrq.gov/issue/development-high-value-care-culture-survey-modified-delphi-process-and-psychometric
December 22, 2018 - Download Citation
Related Resources From the Same Author(s)
What happened
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psnet.ahrq.gov/issue/paediatric-international-patient-safety-and-quality-community
September 30, 2015 - October 6, 2021
The Emperor’s New Clothes: Or Whatever Happened To “Human Error”?
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psnet.ahrq.gov/issue/managing-alarms-acute-care-across-life-span-electrocardiography-and-pulse-oximetry
April 01, 2019 - Related Resources From the Same Author(s)
WebM&M Cases
What Happened