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Showing results for "happened".

1901. Envisioning Patient Safety in the Year 2025: Eight Perspectives (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Henriksen_104.pdf
      January 01, 2025 - , curiosity (How could this have happened?), and commitment (This will never happen again.)

1902. Strategy 2: Communicating to Improve Quality (Implementation Handbook) (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy2/Strat2_Implement_Hndbook_508.pdf
      April 30, 2013 - • What happened during training that could challenge or facilitate implementation?

1903. Common Cause Analysis: Focus on Institutional Change (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Browne_5.pdf
      January 20, 2008 - What happened? 2. What usually happens? 3. What should happen?

1904. How to Identify and Manage Problem Behaviors | PSNet
      psnet.ahrq.gov/perspective/how-identify-and-manage-problem-behaviors
      December 01, 2009 - We want to let patients know that we're committed to understanding what happened, and as soon as we get

1905. In Conversation with…Gerald B. Hickson, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-withgerald-b-hickson-md
      December 01, 2009 - We want to let patients know that we're committed to understanding what happened, and as soon as we get

1906. Opioid Overdose as a Patient Safety Problem | PSNet
      psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem
      May 01, 2017 - It happened in less than 1% of patients."

1907. In Conversation With… David Juurlink, MD, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-david-juurlink-md-phd
      May 22, 2017 - It happened in less than 1% of patients."

1908. Module 2: How To Manage Change | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/workshop/guide2.html
      October 01, 2017 - Module 2: How To Manage Change Training Guide Module Aim The aim of this module is to support change in your organization to maximize the possibility of successful implementation of the Pressure Injury Prevention Program. Module Goals The goals of Module 2 are to identify necessary actions to improve or…

1909. Implement-Facilitator-Guide (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/implement/implement-facilitator-guide.docx
      May 01, 2017 - AHRQ Safety Program for Perinatal Care Implement Teamwork and Communication for Perinatal Safety Implement Teamwork and Communication for Perinatal Safety SAY: The Implement Teamwork and Communication module of the AHRQ Safety Program for Perinatal Care will help you understand the importance of effective communicatio…

1910. 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…

1911. 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…

1912. 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…

1913. 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…

1914. 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…

1915. 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…

1916. 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…

1917. 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…

1918. 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-…

1919. 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…

1920. 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…