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Showing results for "happened".

  1. Pharmacy Survey Webinar Transcript (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/pharmacy/pharmwebinar/psopswebinartrans.pdf
    October 29, 2013 - mistake is made; I don’t like to point fingers at a particular person maybe but take a look at what’s happened

  2. 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…

  3. In Conversation With... Barbara Drew, RN, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-barbara-drew-rn-phd
    May 01, 2016 - In Conversation With... Barbara Drew, RN, PhD May 1, 2016  Also Read an Essay Citation Text: In Conversation With.. Barbara Drew, RN, PhD. PSNet [internet]. 2016.In Conversation With... Barbara Drew, RN, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare…

  4. Cerner-Q-A-Session (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/cerner-q-a-session.pdf
    June 02, 2025 - 1 EHR Q&A Sessions Introduction Prior to each EHR Q&A event, participants were asked to submit questions related to the implementation of automatic referral in Meditech, Epic, and Cerner. Most questions concerned diagnostic codes, embedding automatic referral into order sets, getting buy-in from physicians regar…

  5. Section 5: Determining Where To Focus Efforts To Improve Patient Experience (Page 2 of 2) | Agency for Healthcare Research and Quality

    www.ahrq.gov/cahps/quality-improvement/improvement-guide/5-determining-focus/section5part2.html
    January 01, 2020 - Section 5: Determining Where To Focus Efforts To Improve Patient Experience (Page 2 of 2) Contents On Page 1 of 2: 5.A. Analyze CAHPS Survey Results 5.B. Analyze Other Sources of Information for Related Information Page 2 of 2: 5.C. Evaluate the Process of Care Delivery 5.D. Gather Input From Stakeh…

  6. Implementation Guide: MRSA and SSI Prevention (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-surgery/147-implementation-guide.pdf
    April 01, 2025 - Implementation Guide: MRSA and SSI Prevention AHRQ Safety Program for MRSA Prevention: Targeting SSI Implementation Guide: MRSA and SSI Prevention Surgical Services For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries Introduction Setting up or improving a methicillin-resistant Stap…

  7. Diagnostic Errors: A New Chapter in Patient Safety Science, Policy, and Practice | PSNet

    psnet.ahrq.gov/perspective/diagnostic-errors-new-chapter-patient-safety-science-policy-and-practice
    January 01, 2016 - Diagnostic Errors: A New Chapter in Patient Safety Science, Policy, and Practice Hardeep Singh, MD, MPH | January 1, 2016  Also Read a Conversation View more articles from the same authors. Citation Text: Singh H. Diagnostic Errors: A New Chapter in Patient Safe…

  8. In Conversation with...James P. Bagian, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-withjames-p-bagian-md
    September 01, 2006 - In Conversation with...James P. Bagian, MD September 1, 2006  Also Read an Essay Also Read an Essay Citation Text: In Conversation with..James P. Bagian, MD. PSNet [internet]. 2006.In Conversation with...James P. Bagian, MD. PSNet [internet]. Rockville (MD): Ag…

  9. In Conversation with...David Marx, JD | PSNet

    psnet.ahrq.gov/perspective/conversation-withdavid-marx-jd
    October 01, 2007 - What has happened, I believe, is that we're seeing some drift on time outs.

  10. User-Centered Quality Report (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/podcasts/user-centered-quality-reports-mcgee-20120301-transcript.pdf
    June 02, 2025 - the end it isn't as valuable as just having a live demo where you kind of walk through, here's what happened

  11. 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…

  12. 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…

  13. 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…

  14. 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…

  15. 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…

  16. 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…

  17. 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…

  18. 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-…

  19. 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…

  20. 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…
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