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Showing results for "happened".

1861. Impact of a reengineered electronic error-reporting system on medication event reporting and care process improvements at an urban medical center. | PSNet
      psnet.ahrq.gov/issue/impact-reengineered-electronic-error-reporting-system-medication-event-reporting-and-care
      December 29, 2014 - Study Impact of a reengineered electronic error-reporting system on medication event reporting and care process improvements at an urban medical center. Citation Text: McKaig D, Collins C, Elsaid KA. Impact of a reengineered electronic error-reporting system on medication event reporting…

1862. Quality Improvement Study Framework (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/implementation-guide/appendix-k-study-elements.docx
      June 02, 2025 - Quality Improvement Study Framework Element Definition Things To Keep in Mind The Purpose Define the problem and why it is important. · Avoid suggesting causes in the purpose statement. Cause determination will come later after the data have been analyzed. · Speculating about the cause of a problem before a th…

1863. Displaying Patient Photos in Medical Records Reduces Errors, Improves Patient Safety | Digital Healthcare Research
      digital.ahrq.gov/program-overview/research-stories/displaying-patient-photos-medical-records-reduces-errors-improves
      January 01, 2023 - Displaying Patient Photos in Medical Records Reduces Errors, Improves Patient Safety Theme: Supporting Health Systems in Advancing Care Delivery Subtheme: Optimizing Patient Safety Using Digital Healthcare Solutions Patient photos displayed in the electronic health record significantly red…

1864. Research Spotlight | Digital Healthcare Research
      digital.ahrq.gov/program-overview/research-reports/2022-year-review/research-spotlight
      January 01, 2022 - Research Spotlight The Algorithm Is In: Is Adoption of Healthcare AI Outpacing Understanding? Our Nation’s strategy for better healthcare hinges on putting digital technologies to work. Today’s powerful tools make it easier to capture and share patient information, coordinate care, and strea…

1865. The Anesthesiology Control Tower: Like Air Traffic Control for Operating Rooms | Digital Healthcare Research
      digital.ahrq.gov/2020-year-review/research-summary/anesthesiology-control-tower-air-traffic-control-operating-rooms
      January 01, 2020 - The Anesthesiology Control Tower: Like Air Traffic Control for Operating Rooms Using algorithms for real-time monitoring during surgery can predict and prevent adverse outcomes, leading to better outcomes for patients. Principal Investigator: Avidan, Michael Organization: Washington University…

1866. 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;…

1867. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/838180/psn-pdf
      January 01, 2023 - To err is human, but what happens when surgeons err? September 28, 2022 Lin JS, Olutoye OO, Samora JB. To err is human, but what happens when surgeons err? J Pediatr Surg. 2023;58(3):496-502. doi:10.1016/j.jpedsurg.2022.06.019. https://psnet.ahrq.gov/issue/err-human-what-happens-when-surgeons-err Clinicians involv…

1868. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/850356/psn-pdf
      June 14, 2023 - Prescribing errors in children: why they happen and how to prevent them. June 14, 2023 Conn R, Fox A, Carrington A, et al. Prescribing errors in children: why they happen and how to prevent them. Pharmaceutical Journal. 2023;310:7973. doi:10.1211/pj.2023.1.184013. https://psnet.ahrq.gov/issue/prescribing-errors-ch…

1869. 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…

1870. 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…

1871. 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…

1872. 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…

1873. 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…

1874. 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…

1875. 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…

1876. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35181/psn-pdf
      June 23, 2009 - Communication during trauma resuscitation: do we know what is happening? June 23, 2009 Bergs EAG, Rutten FLPA, Tadros T, et al. Communication during trauma resuscitation: do we know what is happening? Injury. 2005;36(8):905-11. https://psnet.ahrq.gov/issue/communication-during-trauma-resuscitation-do-we-know-what-…

1877. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44359/psn-pdf
      January 06, 2016 - What happens when healthcare innovations collide? January 6, 2016 Pendharkar SR, Woiceshyn J, da Silveira GJC, et al. What happens when healthcare innovations collide? BMJ Qual Saf. 2016;25(1):9-13. doi:10.1136/bmjqs-2015-004441. https://psnet.ahrq.gov/issue/what-happens-when-healthcare-innovations-collide Innovat…

1878. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44132/psn-pdf
      May 13, 2015 - Adverse outcomes: why bad things happen to good people. May 13, 2015 Sonnenberg A. Adverse outcomes: why bad things happen to good people. Clin Gastroenterol Hepatol. 2015;13(5):820-3.e1. doi:10.1016/j.cgh.2014.07.064. https://psnet.ahrq.gov/issue/adverse-outcomes-why-bad-things-happen-good-people This commentary…

1879. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47757/psn-pdf
      February 06, 2019 - Doctors make mistakes. A new documentary explores what happens when they do—and how to fix it. February 6, 2019 Park A. Time Magazine. January 24, 2019. https://psnet.ahrq.gov/issue/doctors-make-mistakes-new-documentary-explores-what-happens-when-they- do-and-how-fix-it This news article reports on the documentar…

1880. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46506/psn-pdf
      October 11, 2017 - Getting Ahead of Harm Before It Happens: A Guide About Proactive Analysis for Improving Surgical Care Safety. October 11, 2017 Wiley K, Davies JM. Edmonton, AB: Canadian Patient Safety Institute; 2017. https://psnet.ahrq.gov/issue/getting-ahead-harm-it-happens-guide-about-proactive-analysis-improving- surgical-car…