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Total Results: 1,692 records

Showing results for "happened".

381. 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.

382. 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…

383. 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

384. 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

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. 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

387. 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.

388. 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

389. 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

390. 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

391. New Insights on Safety and Health IT | PSNet
     psnet.ahrq.gov/perspective/new-insights-safety-and-health-it
     August 01, 2015 - If an error happened on the floor in the old days, the nurse would have tapped the doctor on the shoulder … better for rheumatoid arthritis through a lengthy complex double blind trial, we'll be looking at what happened

392. In Conversation With… Robert M. Wachter, MD | PSNet
     psnet.ahrq.gov/perspective/conversation-robert-m-wachter-md
     August 01, 2015 - If an error happened on the floor in the old days, the nurse would have tapped the doctor on the shoulder … better for rheumatoid arthritis through a lengthy complex double blind trial, we'll be looking at what happened

393. 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…

394. Preventing lawsuits: Coalition pushes apologies and cash up-front. Dealing with medical errors when they happen--instead of in court--can benefit doctors and patients, supporters say. | PSNet
     psnet.ahrq.gov/issue/preventing-lawsuits-coalition-pushes-apologies-and-cash-front-dealing-medical-errors-when
     February 20, 2019 - Newspaper/Magazine Article Preventing lawsuits: Coalition pushes apologies and cash up-front. Dealing with medical errors when they happen--instead of in court--can benefit doctors and patients, supporters say. Citation Text: Preventing lawsuits: Coalition pushes apologies and cash up-fr…

395. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33841/psn-pdf
     September 01, 2017 - federal funding really changed the inflection point and pushed adoption faster than it would have happened

396. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/848124/psn-pdf
     April 26, 2023 - We all saw the NFL game where the football player got a good resuscitation because it happened immediately … And if so, what happened and what can we learn from them to move this forward?

397. On O.R. Off? | PSNet
     psnet.ahrq.gov/web-mm/or
     August 22, 2013 - to keep the team aware of the plan of care would have provided many opportunities to preclude what happened

398. 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…

399. In Conversation With… Vineet Arora, MD, MAPP | PSNet
     psnet.ahrq.gov/perspective/conversation-vineet-arora-md-mapp
     May 31, 2023 - They told me about a case in which a test had happened 5 years prior, but it was buried somewhere in

400. In Conversation With… Lucian Leape, MD | PSNet
     psnet.ahrq.gov/perspective/conversation-lucian-leape-md
     June 12, 2019 - And there probably are some things that have happened along the way that you might not have anticipated