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Showing results for "happened".

1701. Organizational Embrace of CUSP to Improve Patient Safety (Transcript) | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/toolkit/content-calls/embrace.html
      April 01, 2013 - Sean Maxwell: What actually happened was that we had two instances where medication errors happened.

1702. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/857060/psn-pdf
      November 27, 2023 - The Role of Undergraduate Nursing Education in Patient Safety November 27, 2023 Stanley J, Gale B, Mossburg S. The Role of Undergraduate Nursing Education in Patient Safety. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/role-undergraduate-nursing-education-patient-safety Introduction Nurses are a li…

1703. Spotlight (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.461_slideshow.ppt
      November 01, 2018 - Spotlight Spotlight Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees * Source and Credits This presentation is based on the November 2018 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Olle ten C…

1704. Transcript: How To Empower Nurses To Effectively Implement a Nurse-Driven Protocol for Removing Urinary Catheters, Including How To Obtain Buy-In From Physicians (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/empowering-nurses-transcript.pdf
      April 01, 2022 - Transcript: How To Empower Nurses To Effectively Implement a Nurse-Driven Protocol for Removing Urinary Catheters, Including How To Obtain Buy-In From Physicians AHRQ Safety Program for Intensive Care Units: Preventing CLABSI and CAUTI AHRQ Safety Program for Intensive Care Units: Preventing CLABSI and CAUT…

1705. Module-3-Slides (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-3-slides.pdf
      February 09, 2022 - Understanding Your Workflow Processes to Prepare for Systems Change S te v e n Ke tey i a n , P h D M c Ke n z i e Pe c k m a n , M S , AC S M - C E P Module 3 Today’s Training Session 2 PURPOSE Training sessions guided by the Million Hearts®/AACVPR Cardiac Rehabilitation Change Package (CRCP), locate…

1706. Strategies for Improving Patient Experience with Ambulatory Care: Shared Decision-Making (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/communication/cahps-strategy-section-6-i.pdf
      July 01, 2017 - Strategies for Improving Patient Experience with Ambulatory Care: Shared Decision-Making The CAHPS Ambulatory Care Improvement Guide Practical Strategies for Improving Patient Experience Section 6: Strategies for Improving Patient Experience with Ambulatory Care 6.I. Shared Decision-Making Visit the AHRQ We…

1707. Performing SSI Investigations: Slide Presentation
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_ssi_investigation.pptx
      December 01, 2017 - Performing SSI Investigations: Slide Presentation Performing an SSI Investigation AHRQ Safety Program for Surgery Onboarding AHRQ Pub No. 16(18)-0004-15-EF December 2017 SAY: In this module, you’ll learn about performing a surgical site infection or SSI investigation. 1 Learning Objectives After this session, you …

1708. 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…

1709. 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…

1710. 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…

1711. 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-…

1712. 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…

1713. 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;…

1714. 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…

1715. 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…

1716. 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…

1717. 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…

1718. 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…

1719. 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…

1720. 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…