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Total Results: 4,075 records

Showing results for "happened".

2081. Safety in Radiology | PSNet
      psnet.ahrq.gov/perspective/safety-radiology
      October 01, 2013 - What really raised awareness of the issue was radiation overdoses at Cedars-Sinai in 2009—though it happened … the doses are just really high so you see the harm right away—the deterministic effect—that's what happened

2082. Institutional Review Board Approval of Practice-based Research Network Patient Safety Studies (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Graham.pdf
      April 14, 2004 - The AAFP PSRS accepted anonymous reports from clinicians, staff, and patients concerning events that happened … in the practice “that should not have happened and that you don’t want to happen again.”

2083. Paul Tedrick (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/mindfulness-transcript.doc
      June 10, 2014 - You can see in the pie chart to the left, that shows what happened during the antibiotic timeouts. … And in 25 percent of cases, the little pink slice, an intervention happens that would not have happened

2084. Sustaining Change Webinar Transcript | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cauti-tools/archived-webinars/sustaining-change-transcript.html
      December 01, 2017 - Nothing really happened. Four days later, on his day of admission, he didn't show up for breakfast.

2085. Sustaining-Change-Transcript (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/sustaining-change-transcript.docx
      April 14, 2015 - Nothing really happened. Four days later, on his day of admission, he didn't show up for breakfast.

2086. Final Progress Report: Quality Care and Error Reduction in Rural Hospitals (pdf file)
      www.ahrq.gov/sites/default/files/2024-12/cook-hoas-report.pdf
      January 01, 2024 - To overcome this resistance, we began asking if the depicted situation has happened or could happen

2087. Deciphering the Code | PSNet
      psnet.ahrq.gov/web-mm/deciphering-code
      November 16, 2022 - nursing staff, who would have also documented the order in their nursing records (neither of which happened

2088. "Recurrent" Appendicitis | PSNet
      psnet.ahrq.gov/web-mm/recurrent-appendicitis
      January 15, 2020 - limited visual field, two-dimensional image, and lack of tactile feedback for the surgeon.( 10 ) What happened

2089. The Hidden Danger of Unseen Intravenous Catheters | PSNet
      psnet.ahrq.gov/web-mm/hidden-danger-unseen-intravenous-catheters
      October 04, 2023 - intravenous catheter placement may result in dislodgment of the catheter into the subcutaneous tissue as happened

2090. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49638/psn-pdf
      January 01, 2012 - Yet, if that is all that happened, the next child in this same condition in this same institution will

2091. New Patient Mistakenly Checked in as Another | PSNet
      psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another
      October 01, 2013 - Both the patient and the receptionist were new to the practice, the patient happened to be the same age

2092. Spotlight (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.464_slideshow.ppt
      January 01, 2019 - drive to improve safety in the hospital setting Much of the foundational work and research has not happened

2093. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.269_slideshow.ppt
      June 01, 2012 - Troubles (5) Although it was not completely clear to the orthopedic team or anesthesiologists what happened

2094. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49863/psn-pdf
      May 01, 2019 - In such a situation, the entire team would know that something had happened to the blade, allowing them

2095. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49593/psn-pdf
      October 01, 2009 - from any systematic study, both published case reports (1-4) and anecdotal evidence suggest that what happened

2096. Continuing Education | PSNet
      psnet.ahrq.gov/continuing-education
      February 26, 2025 - and embarrassed that the patient remembered waking up during the operation but could not explain what happened

2097. Health Information Exchange | Digital Healthcare Research
      digital.ahrq.gov/health-information-exchange-2
      January 01, 2023 - The Santa Barbara County Care Data Exchange: What Happened?

2098. An American View of the UK's Patient Safety Enterprise: Top Down vs. Bottom Up | PSNet
      psnet.ahrq.gov/perspective/american-view-uks-patient-safety-enterprise-top-down-vs-bottom
      December 01, 2005 - I found myself asking whether a checklist-like story could have happened in the UK, based on the system's

2099. A Mistaken Dose of Naloxone  | PSNet
      psnet.ahrq.gov/web-mm/mistaken-dose-naloxone
      March 21, 2009 - He called the 24 x 7 cancer center helpline and described what happened.

2100. Psi90 Factsheet Faq (pdf file)
      qualityindicators.ahrq.gov/News/PSI90_Factsheet_FAQ.pdf
      August 31, 2016 - without that safety-related event over up to one year after the discharge during which the index event happened