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effectivehealthcare.ahrq.gov/sites/default/files/hesse.pdf
January 01, 2010 - Hesse
Slide 1: Collaborating
for Health: Engaging
Community Intelligence for Better
Patient
Outcomes
Bradford W. Hesse,
Ph.D.
Chief, Health Communication and Informatics Research Branch
National Cancer
Institute,
Rockville,
MD
Slide 2: Emergence of the…
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hcup-us.ahrq.gov/reports/factsandfigures/2009/exhibit1_5.jsp
January 01, 2009 - Facts and Figures Exhibit 1.5
An official website of the Department of Health & Human Services
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy3/Strat3_Implement_Hndbook_508.docx
August 01, 2010 - What happened during training that could challenge or facilitate implementation?
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psnet.ahrq.gov/perspective/emergence-trigger-tool-premier-measurement-strategy-patient-safety
May 01, 2012 - I take the long-term view that if you look at what happened in the airlines, it took them decades to
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psnet.ahrq.gov/perspective/conversation-withdavid-c-classen-md-ms
May 01, 2012 - I take the long-term view that if you look at what happened in the airlines, it took them decades to
-
psnet.ahrq.gov/node/49639/psn-pdf
November 01, 2011 - When the pharmacist had him spell the name on the box, she realized
what had happened and had him discard
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psnet.ahrq.gov/node/841139/psn-pdf
December 14, 2022 - The patient should be informed of what happened
under anesthesia in the recent operation (with the assistance
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psnet.ahrq.gov/node/852808/psn-pdf
August 30, 2023 - When that
communication finally happened, it improved the patient’s course of care.
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psnet.ahrq.gov/sites/default/files/2023-08/spotlight_case_prolonged_dka_in_pregnancy_-_slides_-_revised.pdf
January 01, 2023 - impending transfer to an outside hospital.
10
Background (2)
• When that communication finally happened
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psnet.ahrq.gov/node/49828/psn-pdf
May 01, 2018 - The rheumatologist happened to have two patients with the same last name,
and both had GCA.
-
psnet.ahrq.gov/node/49864/psn-pdf
June 01, 2019 - He was
shocked to find that the correct patient was in the next room and happened to have the same last
-
www.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/chapter5.html
August 01, 2022 - call/near miss), the location of the event, the people involved, and basic information regarding what happened
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psnet.ahrq.gov/node/49627/psn-pdf
June 01, 2011 - What exactly happened here?
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psnet.ahrq.gov/node/49762/psn-pdf
June 01, 2016 - https://psnet.ahrq.gov/web-mm/case-mistaken-intubation
The inpatient team happened to be the same team
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psnet.ahrq.gov/node/33842/psn-pdf
January 01, 2018 - ref9
https://psnet.ahrq.gov//#table
https://psnet.ahrq.gov//#ref10
https://psnet.ahrq.gov//#ref11
happened
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psnet.ahrq.gov/web-mm/who-nose-where-airway
May 01, 2016 - any systematic study, both published case reports ( 1-4 ) and anecdotal evidence suggest that what happened
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psnet.ahrq.gov/web-mm/good-catch-operating-room
August 27, 2017 - In such a situation, the entire team would know that something had happened to the blade, allowing them
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psnet.ahrq.gov/node/73434/psn-pdf
June 30, 2021 - it adequate to describe the finding and to
suggest follow-up in the written report, which is what happened
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psnet.ahrq.gov/web-mm/discharging-our-responsibility
January 16, 2019 - When asked by the admitting physician what happened, the patient replied, "You know, I was feeling pretty
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psnet.ahrq.gov/web-mm/mechanical-prosthetic-valve-thrombosis-thromboembolism
August 21, 2005 - Consultation
July 29, 2020
WebM&M Cases
What Happened