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Showing results for "happened".

341. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50719/psn-pdf
     December 04, 2019 - A lot happens when you report a hazard or error to ISMP—there’s no “black hole” here! December 4, 2019 ISMP Medication Safety Alert! Acute Care Edition. November 7, 2019 https://psnet.ahrq.gov/issue/lot-happens-when-you-report-hazard-or-error-ismp-theres-no-black-hole-here The reporting and analysis of incidents i…

342. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46506/psn-pdf
     October 11, 2017 - Getting Ahead of Harm Before It Happens: A Guide About Proactive Analysis for Improving Surgical Care Safety. October 11, 2017 Wiley K, Davies JM. Edmonton, AB: Canadian Patient Safety Institute; 2017. https://psnet.ahrq.gov/issue/getting-ahead-harm-it-happens-guide-about-proactive-analysis-improving- surgical-car…

343. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/836877/psn-pdf
     May 16, 2022 - If we don't notice that a mistake happened, it's very hard to report and it's very hard to improve upon … For something that happened hours ago, am I going to accurately remember what time I gave each medication

344. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39080/psn-pdf
     November 04, 2009 - How could this happen? November 4, 2009 Westfall SS; Mascia K. People. October 5, 2009. https://psnet.ahrq.gov/issue/how-could-happen This story discusses an instance of mistakenly implanted embryos and the impact of the error on the two families involved. https://psnet.ahrq.gov/issue/how-could-happen

345. In Conversation With…Christine A. Sinsky, MD | PSNet
     psnet.ahrq.gov/perspective/conversation-withchristine-sinsky-md
     February 26, 2025 - That takes effort, and I don't think that's happened as much as it could. … We probably didn't talk about how great it was when this or that happened. … But we talked more about how frustrating it was when negative things happened.

346. Fatal Error in Neonate: Does "Just Culture" Provide an Answer? | PSNet
     psnet.ahrq.gov/web-mm/fatal-error-neonate-does-just-culture-provide-answer
     June 24, 2020 - Finally, look at how often (and under what circumstances) this or something similar has happened, either … It is about telling stories of what happened.

347. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47914/psn-pdf
     May 22, 2019 - Hospitals look to computers to predict patient emergencies before they happen. May 22, 2019 Ross C. STAT. May 13, 2019. https://psnet.ahrq.gov/issue/hospitals-look-computers-predict-patient-emergencies-they-happen Nuisance alarms, interruptions, and insufficient staff availability can hinder effective monitoring …

348. Prescribing errors in children: why they happen and how to prevent them. | PSNet
     psnet.ahrq.gov/issue/prescribing-errors-children-why-they-happen-and-how-prevent-them
     December 13, 2017 - Newspaper/Magazine Article Prescribing errors in children: why they happen and how to prevent them. Citation Text: Conn R, Fox A, Carrington A, et al. Prescribing errors in children: why they happen and how to prevent them. Pharmaceutical Journal. 2023;310:7973. doi:10.1211/pj.2023.1.184…

349. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40815/psn-pdf
     September 28, 2011 - Program encourages reporting accidents waiting to happen: the Good Catch Awards. September 28, 2011 Minnesota Hospital Association. https://psnet.ahrq.gov/issue/program-encourages-reporting-accidents-waiting-happen-good-catch-awards This news article highlights a program at Johns Hopkins Medicine that engages clin…

350. In Conversation with...Steven J. Spear, DBA, MS, MS | PSNet
     psnet.ahrq.gov/perspective/conversation-withsteven-j-spear-dba-ms-ms
     August 01, 2009 - Similar to what happened in Boston, a bunch of people stood up and said, "Well, we've tried everything … Why do you think the problem happened? What can we do to help?" … proves to be a difficult problem, are part of the constant experimentation to discover why the problem happened … How could that have happened?" … don't avoid meeting the patient's needs but call attention to the problem so we can understand why it happened

351. Workarounds and Resiliency on the Front Lines of Health Care | PSNet
     psnet.ahrq.gov/perspective/workarounds-and-resiliency-front-lines-health-care
     August 01, 2009 - Similar to what happened in Boston, a bunch of people stood up and said, "Well, we've tried everything … Why do you think the problem happened? What can we do to help?" … proves to be a difficult problem, are part of the constant experimentation to discover why the problem happened … How could that have happened?" … don't avoid meeting the patient's needs but call attention to the problem so we can understand why it happened

352. In Conversation with...Sorrel King | PSNet
     psnet.ahrq.gov/perspective/conversation-withsorrel-king
     March 01, 2007 - After we signed the legal papers, I called Rick Kidwell, the lawyer at Hopkins, and said, "What happened … They're great things that happened.

353. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73222/psn-pdf
     May 05, 2021 - Fatal mistakes: why do ten-fold medication errors in children keep happening? May 5, 2021 Parry C. The Pharmaceutical Journal.  April 22 2021. https://psnet.ahrq.gov/issue/fatal-mistakes-why-do-ten-fold-medication-errors-children-keep-happening Weight-based prescribing in children harbors challenges to accura…

354. Hospitals look to computers to predict patient emergencies before they happen. | PSNet
     psnet.ahrq.gov/issue/hospitals-look-computers-predict-patient-emergencies-they-happen
     June 16, 2021 - Newspaper/Magazine Article Hospitals look to computers to predict patient emergencies before they happen. Citation Text: Hospitals look to computers to predict patient emergencies before they happen. Ross C. STAT. May 13, 2019. Copy Citation Save Save to your libr…

355. A lot happens when you report a hazard or error to ISMP—there’s no “black hole” here! | PSNet
     psnet.ahrq.gov/issue/lot-happens-when-you-report-hazard-or-error-ismp-theres-no-black-hole-here
     December 27, 2018 - Newspaper/Magazine Article A lot happens when you report a hazard or error to ISMP—there’s no “black hole” here! Citation Text: A lot happens when you report a hazard or error to ISMP—there’s no “black hole” here! ISMP Medication Safety Alert! Acute Care Edition. November 7, 2019 Cop…

356. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49824/psn-pdf
     March 01, 2018 - Transmission of the ECG may be hampered by technical problems, as happened in this case. … What happened in this case represents a failed handoff of care.

357. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49473/psn-pdf
     March 01, 2005 - to keep the team aware of the plan of care would have provided many opportunities to preclude what happened

358. Program encourages reporting accidents waiting to happen: the Good Catch Awards. | PSNet
     psnet.ahrq.gov/issue/program-encourages-reporting-accidents-waiting-happen-good-catch-awards
     February 13, 2013 - Newspaper/Magazine Article Program encourages reporting accidents waiting to happen: the Good Catch Awards. Citation Text: Program encourages reporting accidents waiting to happen: the Good Catch Awards. Minnesota Hospital Association. Copy Citation Save Save …

359. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44327/psn-pdf
     August 26, 2015 - Safely Home: What Happens When People Leave Hospital Care Settings? August 26, 2015 London, UK: Healthwatch England; July 2015. https://psnet.ahrq.gov/issue/safely-home-what-happens-when-people-leave-hospital-care-settings Discharges are vulnerable periods for patients, often due to miscommunication, delays, and l…

360. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33801/psn-pdf
     February 01, 2016 - That takes effort, and I don't think that's happened as much as it could. … We probably didn't talk about how great it was when this or that happened. … But we talked more about how frustrating it was when negative things happened.