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Total Results: 1,790 records

Showing results for "happened".

381. Fatal PCA adverse events continue to happen...better patient monitoring is essential to prevent harm. | PSNet
     psnet.ahrq.gov/issue/fatal-pca-adverse-events-continue-happenbetter-patient-monitoring-essential-prevent-harm
     June 10, 2018 - Newspaper/Magazine Article Fatal PCA adverse events continue to happen...better patient monitoring is essential to prevent harm. Citation Text: Fatal PCA adverse events continue to happen...better patient monitoring is essential to prevent harm. ISMP Medication Safety Alert! Acute Care E…

382. 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

383. 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

384. 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

385. Surgical safety does not happen by accident: learning from perioperative near miss case studies. | PSNet
     psnet.ahrq.gov/issue/surgical-safety-does-not-happen-accident-learning-perioperative-near-miss-case-studies
     August 04, 2021 - Commentary Surgical safety does not happen by accident: learning from perioperative near miss case studies. Citation Text: Stucky CH, Michael Hartmann J, Yauger YJ, et al. Surgical safety does not happen by accident: learning from perioperative near miss case studies. J Perianesth Nurs. …

386. Getting Ahead of Harm Before It Happens: A Guide About Proactive Analysis for Improving Surgical Care Safety. | PSNet
     psnet.ahrq.gov/issue/getting-ahead-harm-it-happens-guide-about-proactive-analysis-improving-surgical-care-safety
     November 30, 2016 - Book/Report Getting Ahead of Harm Before It Happens: A Guide About Proactive Analysis for Improving Surgical Care Safety. Citation Text: Getting Ahead of Harm Before It Happens: A Guide About Proactive Analysis for Improving Surgical Care Safety. Wiley K, Davies JM. Edmonton, AB: Canadia…

387. 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?"

388. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47861/psn-pdf
     April 24, 2019 - Laney's story: the problem of delayed diagnosis of pediatric stroke. April 24, 2019 Fitzsimons BT, Fitzsimons LL, Sun LR. Laney's Story: The Problem of Delayed Diagnosis of Pediatric Stroke. Pediatrics. 2019;143(4):e20183458. doi:10.1542/peds.2018-3458. https://psnet.ahrq.gov/issue/laneys-story-problem-delayed-dia…

389. In Conversation With... Remle P. Crowe, PhD | PSNet
     psnet.ahrq.gov/perspective/conversation-remle-p-crowe-phd
     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

390. Identifying Safety Events in the Prehospital Setting | PSNet
     psnet.ahrq.gov/perspective/identifying-safety-events-prehospital-setting
     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

391. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867652/psn-pdf
     February 26, 2025 - adverse events, holding a short, focused meeting as soon as possible after the event to describe what happened

392. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33611/psn-pdf
     July 01, 2005 - However, it turned out that this kind of thing happened only a handful of times over the life of the

393. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35766/psn-pdf
     March 02, 2011 - Unexpected hypoglycemia in a critically ill patient. March 2, 2011 Bates DW. Unexpected hypoglycemia in a critically ill patient. Ann Intern Med. 2002;137(2):110-6. https://psnet.ahrq.gov/issue/unexpected-hypoglycemia-critically-ill-patient This case study shares the experiences of a patient who suffered a medicati…

394. Surgical errors happen, but are learners trained to recover from them? A survey of North American surgical residents and fellows. | PSNet
     psnet.ahrq.gov/issue/surgical-errors-happen-are-learners-trained-recover-them-survey-north-american-surgical
     July 28, 2021 - Study Surgical errors happen, but are learners trained to recover from them? A survey of North American surgical residents and fellows. Citation Text: Gabrysz-Forget F, Young M, Zahabi S, et al. Surgical errors happen, but are learners trained to recover from them? A survey of North Amer…

395. The Unhappy Patient Leaves Against Medical Advice. | PSNet
     psnet.ahrq.gov/web-mm/unhappy-patient-leaves-against-medical-advice
     January 31, 2024 - 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

396. Missing ECG and Missed Diagnosis Lead to Dangerous Delay | PSNet
     psnet.ahrq.gov/web-mm/missing-ecg-and-missed-diagnosis-lead-dangerous-delay
     March 01, 2015 - 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.

397. Rethinking Root Cause Analysis | PSNet
     psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
     August 21, 2016 - RCA takes a structured, systems-oriented approach to identify what happened (the course of events), why … an incident happened (the root cause, or causes), and how to prevent it from recurring in the future

398. In Conversation with...Allan Frankel, MD | PSNet
     psnet.ahrq.gov/perspective/conversation-withallan-frankel-md
     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.

399. 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.

400. Intraoperative adverse events in abdominal surgery: what happens in the operating room does not stay in the operating room. | PSNet
     psnet.ahrq.gov/issue/intraoperative-adverse-events-abdominal-surgery-what-happens-operating-room-does-not-stay
     January 23, 2017 - Study Intraoperative adverse events in abdominal surgery: what happens in the operating room does not stay in the operating room. Citation Text: Bohnen JD, Mavros MN, Ramly EP, et al. Intraoperative Adverse Events in Abdominal Surgery: What Happens in the Operating Room Does Not Stay in …