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Total Results: 1,692 records

Showing results for "happened".

441. Building a Safety Program in a Vast Health Care Network | PSNet
     psnet.ahrq.gov/perspective/building-safety-program-vast-health-care-network
     March 01, 2019 - When I asked what happened, the doctor said, "Oh, the name [of the backup physician] is on the wall, … Tell me from your perspective what happened.

442. Annual Perspective: Psychological Safety of Healthcare Staff | PSNet
     psnet.ahrq.gov/perspective/annual-perspective-psychological-safety-healthcare-staff
     November 16, 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.”

443. Prolonged DKA in Pregnancy: A Case of Communication Breakdown. | PSNet
     psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown
     June 28, 2023 - When that communication finally happened, it improved the patient’s course of care. … It happened to me, as a pregnant OB-GYN.

444. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33858/psn-pdf
     May 01, 2018 - 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

445. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33656/psn-pdf
     September 01, 2007 - Very few of us in surgery actually take a look to see what happened at 30 days to monitor whether we're … morning conferences, and he circled back to see her again, instead of waiting all day to see what happened

446. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49531/psn-pdf
     March 01, 2007 - not acknowledging the mistake, the health care team made no attempt to inform the parent of what happened … the physicians and nurses in the unit could have participated in a frank discussion about what had happened

447. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49468/psn-pdf
     December 16, 2004 - Mark My Limb December 1, 2004 Jacott WE, O'Leary D. Mark My Limb. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/mark-my-limb The Case A patient went to the operating room (OR) for surgery on the lower leg. Per the Universal Protocol, the surgeon marked the proper leg prior to bringing the patient to the O…

448. Accreditation and Regulation: Can They Help Improve Patient Safety? | PSNet
     psnet.ahrq.gov/perspective/accreditation-and-regulation-can-they-help-improve-patient-safety
     April 01, 2009 - We have imperfect tools to assess exactly what happened in the course of an adverse event. … But knowing what happened in one is not enough information to understand what the vulnerabilities are

449. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33788/psn-pdf
     June 01, 2015 - In Conversation With… Christine Cassel, MD June 1, 2015 In Conversation With… Christine Cassel, MD. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/conversation-christine-cassel-md Editor's note: Christine Cassel, MD, is President and CEO of the National Quality Forum (NQF). Dr. Cassel, one of the foun…

450. Spotlight Case July 2008 (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.254_slideshow.ppt
     November 01, 2011 - When the pharmacist had him spell the name on the label, she realized what had happened and had him discard

451. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/855058/psn-pdf
     October 31, 2023 - quality—such as root-cause analysis, rapid response teams, and event debriefing—to understand what happened

452. In Conversation With… Tejal K. Gandhi, MD, MPH | PSNet
     psnet.ahrq.gov/perspective/conversation-tejal-k-gandhi-md-mph
     February 26, 2025 - specialists who can do the more complex problems as well as do the more complex analyses of why an error happened

453. Safety I, Safety II, and the New Views of Safety | PSNet
     psnet.ahrq.gov/primer/safety-i-safety-ii-and-new-views-safety
     October 02, 2024 - The Emperor’s New Clothes: Or Whatever Happened To “Human Error”? Chapter In: Dekker SWA, ed.

454. In Conversation With… Harlan Krumholz, MD, SM | PSNet
     psnet.ahrq.gov/perspective/conversation-harlan-krumholz-md-sm
     April 01, 2018 - We never saw them as a tool for communication or as essential to communicating what happened in the hospital … Our study showed that they cannot recount the basic facts of their condition or what happened to them

455. In Conversation with...James L. Reinertsen, MD | PSNet
     psnet.ahrq.gov/perspective/conversation-withjames-l-reinertsen-md
     August 01, 2007 - The second thing that happened in many hospitals was that they had a shocking incident. … "How could that have happened here?"

456. The PeaceHealth Governance Journey in Support of Quality and Safety | PSNet
     psnet.ahrq.gov/perspective/peacehealth-governance-journey-support-quality-and-safety
     August 01, 2007 - The second thing that happened in many hospitals was that they had a shocking incident. … "How could that have happened here?"

457. Our Maturing Understanding of Safety Culture: How to Change It and How It Changes Safety | PSNet
     psnet.ahrq.gov/perspective/our-maturing-understanding-safety-culture-how-change-it-and-how-it-changes-safety
     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

458. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33720/psn-pdf
     November 01, 2011 - The same thing has happened in health care.

459. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33764/psn-pdf
     April 01, 2014 - specialists who can do the more complex problems as well as do the more complex analyses of why an error happened

460. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33765/psn-pdf
     April 01, 2014 - We found several examples, but one that was most interesting to the board was what had happened in Los