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Showing results for "happened".

  1. Harvey Cushing's open and thorough documentation of surgical mishaps at the dawn of neurologic surgery. | PSNet

    psnet.ahrq.gov/issue/harvey-cushings-open-and-thorough-documentation-surgical-mishaps-dawn-neurologic-surgery
    November 16, 2022 - Study Harvey Cushing's open and thorough documentation of surgical mishaps at the dawn of neurologic surgery. Citation Text: Latimer K, Pendleton C, Olivi A, et al. Harvey Cushing's open and thorough documentation of surgical mishaps at the dawn of neurologic surgery. Arch Surg. 2011;1…

  2. The Silent Treatment: Why Safety Tools and Checklists Aren't Enough to Save Lives. | PSNet

    psnet.ahrq.gov/issue/silent-treatment-why-safety-tools-and-checklists-arent-enough-save-lives
    April 03, 2009 - Book/Report Classic The Silent Treatment: Why Safety Tools and Checklists Aren't Enough to Save Lives. Citation Text: The Silent Treatment: Why Safety Tools and Checklists Aren't Enough to Save Lives. Maxfield D, Grenny J, Lavandero R, et al. Provo, UT: VitalS…

  3. Effect of outcome on physician judgments of appropriateness of care. | PSNet

    psnet.ahrq.gov/issue/effect-outcome-physician-judgments-appropriateness-care
    June 23, 2015 - Review Classic Effect of outcome on physician judgments of appropriateness of care. Citation Text: Caplan RA, Posner KL, Cheney FW. Effect of outcome on physician judgments of appropriateness of care. JAMA. 1991;265(15):1957-60. Copy Citation Format: …

  4. Perception of feeling safe perioperatively: a concept analysis. | PSNet

    psnet.ahrq.gov/issue/perception-feeling-safe-perioperatively-concept-analysis
    December 21, 2022 - Review Perception of feeling safe perioperatively: a concept analysis. Citation Text: Larsson F, Strömbäck U, Rysst Gustafsson S, et al. Perception of feeling safe perioperatively: a concept analysis. Int J Qual Stud Health Well-being. 2023;18(1):2216018. doi:10.1080/17482631.2023.221601…

  5. Delayed Admissions to the Pediatric Intensive Care Unit: Progression of Disease or Errors in Emergency Department Management | PSNet

    psnet.ahrq.gov/issue/delayed-admissions-pediatric-intensive-care-unit-progression-disease-or-errors-emergency
    June 14, 2019 - Journal Article Delayed Admissions to the Pediatric Intensive Care Unit: Progression of Disease or Errors in Emergency Department Management Citation Text: Czolgosz T, Cashen K, Farooqi A, et al. Delayed Admissions to the Pediatric Intensive Care Unit: Progression of Disease or Errors in…

  6. Avoidable iatrogenic complications of urethral catheterization and inadequate intern training in a tertiary-care teaching hospital. | PSNet

    psnet.ahrq.gov/issue/avoidable-iatrogenic-complications-urethral-catheterization-and-inadequate-intern-training
    March 02, 2011 - Study Avoidable iatrogenic complications of urethral catheterization and inadequate intern training in a tertiary-care teaching hospital. Citation Text: Thomas AZ, Giri SK, Meagher D, et al. Avoidable iatrogenic complications of urethral catheterization and inadequate intern training i…

  7. Reducing surgical specimen errors through multidisciplinary quality improvement. | PSNet

    psnet.ahrq.gov/issue/reducing-surgical-specimen-errors-through-multidisciplinary-quality-improvement
    July 28, 2021 - Study Reducing surgical specimen errors through multidisciplinary quality improvement. Citation Text: Holstine JB, Samora JB. Reducing surgical specimen errors through multidisciplinary quality improvement. Jt Comm J Qual Patient Saf. 2021;47(9):563-571. doi:10.1016/j.jcjq.2021.04.003. …

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/861286/psn-pdf
    January 24, 2024 - Surgical safety does not happen by accident: learning from perioperative near miss case studies. January 24, 2024 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. 2024;39(1):10-15. doi:10.1016/j.jopa…

  9. Zikmund (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/zikmund.pdf
    October 08, 2025 - Zikmund Slide  1: The  Right Tool is What They  Need, Not What We  Have: A Taxonomy  of Appropriate   Levels of Precision in Patient Risk Communication Brian J. Zikmund-­‐Fisher, Ph.D. Assistant Professor, Health Behavior & Health Education University of Michigan School of…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60844/psn-pdf
    August 26, 2020 - Surgical errors happen, but are learners trained to recover from them? A survey of North American surgical residents and fellows. August 26, 2020 Gabrysz-Forget F, Young M, Zahabi S, et al. Surgical errors happen, but are learners trained to recover from them? A survey of North American surgical residents and fell…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60877/psn-pdf
    September 02, 2020 - When bad things happen: training medical students to anticipate the aftermath of medical errors. September 2, 2020 Musunur S, Waineo E, Walton E, et al. When bad things happen: training medical students to anticipate the aftermath of medical errors. Acad Psychiatry. 2020;44(5):586-591. doi:10.1007/s40596-020-01278-…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/843080/psn-pdf
    January 25, 2023 - Bad things can happen: are medical students aware of patient centered care and safety? January 25, 2023 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/dx-2022-0072. https://psnet.ahr…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45664/psn-pdf
    July 02, 2017 - Intraoperative adverse events in abdominal surgery: what happens in the operating room does not stay in the operating room. July 2, 2017 Bohnen JD, Mavros MN, Ramly EP, et al. Intraoperative Adverse Events in Abdominal Surgery: What Happens in the Operating Room Does Not Stay in the Operating Room. Ann Surg. 2017;…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42567/psn-pdf
    September 11, 2013 - What happens to the medication regimens of older adults during and after an acute hospitalization? September 11, 2013 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):150-3. doi:10.1097/PTS.0b013e3182…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45874/psn-pdf
    February 22, 2017 - Ethics in the pediatric emergency department: when mistakes happen: an approach to the process, evaluation, and response to medical errors. February 22, 2017 Dreisinger N, Zapolsky N. Ethics in the Pediatric Emergency Department: When Mistakes Happen: An Approach to the Process, Evaluation, and Response to Medical…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36149/psn-pdf
    September 29, 2010 - When incidents happen. September 29, 2010 Newfield JS. When Incidents Happen. Home Health Care Manag Pract. 2006;18(5). doi:10.1177/1084822306287998. https://psnet.ahrq.gov/issue/when-incidents-happen The author discusses post-incident documentation for the home care setting and addresses legal issues. https://ps…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39923/psn-pdf
    September 03, 2014 - Sued for misdiagnosis? It could happen to you. September 3, 2014 Lippman H, Davenport J. Sued for misdiagnosis? It could happen to you. J Fam Pract. 2010;59(9):498-508. https://psnet.ahrq.gov/issue/sued-misdiagnosis-it-could-happen-you This article explains how to avoid diagnostic error, minimize litigation, and pr…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40194/psn-pdf
    June 20, 2011 - What happens when things go wrong? June 20, 2011 Brandom BW, Callahan P, Micalizzi DA. What happens when things go wrong? Paediatr Anaesth. 2011;21(7):730-6. doi:10.1111/j.1460-9592.2010.03513.x. https://psnet.ahrq.gov/issue/what-happens-when-things-go-wrong This commentary reveals a personal story of loss and dis…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38215/psn-pdf
    November 14, 2011 - Could it happen here? Learning from other organizations' safety errors. November 14, 2011 Conway JB. Could it happen here? Learning from other organizations' safety errors. Healthcare Executive. 2008;23(6):64, 66-67. https://psnet.ahrq.gov/issue/could-it-happen-here-learning-other-organizations-safety-errors This…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39489/psn-pdf
    June 11, 2010 - What happens between visits? Adverse and potential adverse events among a low-income, urban, ambulatory population with diabetes. June 11, 2010 Sarkar U, Handley MA, Gupta R, et al. What happens between visits? Adverse and potential adverse events among a low-income, urban, ambulatory population with diabetes. Qua…
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