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Total Results: 1,692 records

Showing results for "happened".

401. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33863/psn-pdf
     August 01, 2018 - Why hasn't that happened? MW: It's a function of the structure of health care.

402. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33783/psn-pdf
     April 01, 2015 - And there probably are some things that have happened along the way that you might not have anticipated

403. 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…

404. Root Cause Analysis Gone Wrong | PSNet
     psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
     August 28, 2024 - five whys" technique, fishbone diagrams, change analysis, and others), RCA seeks to understand what happened … organizations now invite peer reviewers from outside the department or organization where the incident happened

405. Ethics in the pediatric emergency department: when mistakes happen: an approach to the process, evaluation, and response to medical errors. | PSNet
     psnet.ahrq.gov/issue/ethics-pediatric-emergency-department-when-mistakes-happen-approach-process-evaluation-and
     December 13, 2013 - Review Ethics in the pediatric emergency department: when mistakes happen: an approach to the process, evaluation, and response to medical errors. Citation Text: Dreisinger N, Zapolsky N. Ethics in the Pediatric Emergency Department: When Mistakes Happen: An Approach to the Process, Eval…

406. 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 …

407. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33626/psn-pdf
     January 01, 2006 - JB: What I've seen has paralleled what happened in aviation when people first started requiring team … situations in which this kind of training really prevented an error in health care that would have happened

408. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49829/psn-pdf
     May 01, 2018 - five whys" technique, fishbone diagrams, change analysis, and others), RCA seeks to understand what happened … organizations now invite peer reviewers from outside the department or organization where the incident happened

409. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/836839/psn-pdf
     March 31, 2022 - greater odds of reporting near-miss safety events that were perceived as more serious and “nearly happened … ” versus those that only “could have happened.”

410. 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…

411. In Conversation With… Robert Hirschtick, MD | PSNet
     psnet.ahrq.gov/perspective/conversation-robert-hirschtick-md
     January 01, 2018 - If that happened to be downstairs in radiology with the patient, you couldn't see that chart. … So all of these good things have happened. … She knows what happened overnight. She knows what the labs are.

412. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33754/psn-pdf
     September 01, 2013 - This happened in aviation in the 1970s and 1980s, when pilots resisted the idea of the importance of … sees different things, who has perhaps a completely different overview of the social order of what happened

413. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866848/psn-pdf
     September 25, 2024 - In Conversation with Eric Thomas about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement September 25, 2024 Thomas E, Mossburg S, Lee M. In Conversation with Eric Thomas about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement. …

414. In Conversation With… Sidney Dekker, MA, MSc, PhD | PSNet
     psnet.ahrq.gov/perspective/conversation-sidney-dekker-ma-msc-phd
     February 26, 2025 - This happened in aviation in the 1970s and 1980s, when pilots resisted the idea of the importance of … sees different things, who has perhaps a completely different overview of the social order of what happened

415. Spotlight Case [MONTH] 2003 (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.218_slideshow.ppt
     May 01, 2010 - fairly balance them Look at how often (and under what circumstances) this or something similar has happened

416. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33791/psn-pdf
     September 01, 2015 - They told me about a case in which a test had happened 5 years prior, but it was buried somewhere in

417. In Conversation With… John Halamka, MD, MS | PSNet
     psnet.ahrq.gov/perspective/conversation-john-halamka-md-ms
     March 27, 2024 - Problem two, and I sat in on over 200 committee meetings in the Obama Administration, so I saw how this happened … Let me tell you what happened. … the data and from where I sit as a doctor, I think I'm on Epic, but all sorts of other things have happened

418. What happens between visits? Adverse and potential adverse events among a low-income, urban, ambulatory population with diabetes. | PSNet
     psnet.ahrq.gov/issue/what-happens-between-visits-adverse-and-potential-adverse-events-among-low-income-urban
     February 22, 2011 - Study What happens between visits? Adverse and potential adverse events among a low-income, urban, ambulatory population with diabetes. Citation Text: Sarkar U, Handley MA, Gupta R, et al. What happens between visits? Adverse and potential adverse events among a low-income, urban, ambu…

419. In Conversation With… Eric J. Topol, MD | PSNet
     psnet.ahrq.gov/perspective/conversation-eric-j-topol-md
     February 26, 2025 - It is amazing to me that that has not already happened. It is not that hard to do. … goes between doctor and patient fully captured and processed the way it ought to be, but it has not happened

420. In Conversation With… Mary Dixon-Woods, DPhil | PSNet
     psnet.ahrq.gov/perspective/conversation-mary-dixon-woods-dphil
     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