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Showing results for "happened".

361. 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…

362. 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…

363. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/838972/psn-pdf
     October 27, 2022 - unaware of these events until the on-call physician contacted the unit for more information about what happened … Had this process happened in the current case, the patient may have considered staying in the hospital

364. Application of Safety-II Principles | PSNet
     psnet.ahrq.gov/perspective/application-safety-ii-principles
     August 28, 2024 - Venkatesan: One challenge early on was that when you're asking frontline teams to describe what actually happened … , the tendency of leaders can be to potentially modify the reality of what happened. … In your existing causal analysis, you can ask what normally happens, not what happened in this instance

365. In Conversation with Chalapathy Venkatesan and Kathy Helak about Application of Safety-II Principles | PSNet
     psnet.ahrq.gov/perspective/conversation-chalapathy-venkatesan-and-kathy-helak-about-application-safety-ii
     August 28, 2024 - Venkatesan: One challenge early on was that when you're asking frontline teams to describe what actually happened … , the tendency of leaders can be to potentially modify the reality of what happened. … In your existing causal analysis, you can ask what normally happens, not what happened in this instance

366. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47678/psn-pdf
     December 19, 2018 - When mistakes happen. December 19, 2018 Beck DL. ASH Clinical News. December 1, 2018. https://psnet.ahrq.gov/issue/when-mistakes-happen This article provides an overview of efforts to understand and improve patient safety and covers topics such as the epidemiology of error, its impact on the individuals involved, …

367. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33679/psn-pdf
     January 01, 2009 - occur in one conversation, there will be an entire process that follows to determine what actually happened

368. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867651/psn-pdf
     February 26, 2025 - psnet.ahrq.gov//#4 https://psnet.ahrq.gov//#4 https://psnet.ahrq.gov/issue/emperors-new-clothes-or-whatever-happened-human-error … The Emperor’s New Clothes: Or Whatever Happened To “Human Error”? Chapter In: Dekker SWA, ed.

369. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73302/psn-pdf
     May 26, 2021 - figure out the “why” when you’re looking at errors in clinical care to ensure that we can teach what happened

370. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33837/psn-pdf
     July 01, 2017 - communication-and-resolution-programs-challenges-and-lessons-learned-six-early-adopters patients, provide a full explanation of what happened … , and provide an apology that is appropriate to why the event happened—either "I'm sorry this happened

371. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33784/psn-pdf
     April 01, 2015 - What were your concerns about what could have happened methodologically that might have explained a … And then 3 months later introduce a checklist, look at the outcomes, and compare what happened after … to what happened before.

372. 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…

373. What happens to the medication regimens of older adults during and after an acute hospitalization? | PSNet
     psnet.ahrq.gov/issue/what-happens-medication-regimens-older-adults-during-and-after-acute-hospitalization
     May 19, 2021 - Study What happens to the medication regimens of older adults during and after an acute hospitalization? Citation Text: Harris CM, Sridharan A, Landis R, et al. What happens to the medication regimens of older adults during and after an acute hospitalization? J Patient Saf. 2013;9(3):15…

374. Doctors make mistakes. A new documentary explores what happens when they do—and how to fix it. | PSNet
     psnet.ahrq.gov/issue/doctors-make-mistakes-new-documentary-explores-what-happens-when-they-do-and-how-fix-it
     November 20, 2019 - Newspaper/Magazine Article Doctors make mistakes. A new documentary explores what happens when they do—and how to fix it. Citation Text: Doctors make mistakes. A new documentary explores what happens when they do—and how to fix it. Park A. Time Magazine. January 24, 2019. Copy Citation…

375. 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…

376. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33828/psn-pdf
     March 01, 2017 - And that literature, in fact, predicted the Enron disaster a couple of years before it happened. … How you replicate at scale seems to depend on really understanding what happened when it worked that

377. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33855/psn-pdf
     April 01, 2018 - We never saw them as a tool for communication or as essential to communicating what happened in the … Our study showed that they cannot recount the basic facts of their condition or what happened to them

378. Bad things can happen: are medical students aware of patient centered care and safety? | PSNet
     psnet.ahrq.gov/issue/bad-things-can-happen-are-medical-students-aware-patient-centered-care-and-safety
     July 06, 2022 - Study Bad things can happen: are medical students aware of patient centered care and safety? Citation Text: Gillissen A, Kochanek T, Zupanic M, et al. Bad things can happen: are medical students aware of patient centered care and safety? Diagnosis (Berl). 2023;10(2):110-120. doi:10.1515/…

379. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33654/psn-pdf
     August 01, 2007 - The second thing that happened in many hospitals was that they had a shocking incident. … "How could that have happened here?"

380. Key Issues in Developing a Successful Hospital Safety Program | PSNet
     psnet.ahrq.gov/perspective/key-issues-developing-successful-hospital-safety-program
     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 assure … We described what happened.