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Total Results: 3,987 records

Showing results for "happened".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33771/psn-pdf
    August 22, 2014 - Beyond the Hospital: the New Frontier of Patient Safety August 22, 2014 Plews-Ogan M. Beyond the Hospital: the New Frontier of Patient Safety. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/beyond-hospital-new-frontier-patient-safety Perspective The frontier of patient safety outside the hospital has y…

  2. In Conversation with…Barbara A. Blakeney, MS, RN | PSNet

    psnet.ahrq.gov/perspective/conversation-withbarbara-blakeney-ms-rn
    August 01, 2005 - In Conversation with…Barbara A. Blakeney, MS, RN August 1, 2005  Also Read an Essay Citation Text: In Conversation with…Barbara A. Blakeney, MS, RN. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Ser…

  3. Pre-analytical pitfalls: Missing and mislabeled specimens | PSNet

    psnet.ahrq.gov/web-mm/pre-analytical-pitfalls-missing-and-mislabeled-specimens
    April 18, 2018 - Pre-analytical pitfalls: Missing and mislabeled specimens Citation Text: Tran NK, Liu Y. Pre-analytical pitfalls: Missing and mislabeled specimens . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: …

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866055/psn-pdf
    May 29, 2024 - Reducing Preventable Patient Harm Due to Retained Surgical Items: The RSI Bundle May 29, 2024 https://psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle Summary Retained surgical items (RSIs) cause severe yet preventable patient harm. RSIs are the most common catego…

  5. Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia | PSNet

    psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubation-and-severe-hypoxemia
    January 29, 2021 - Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia Citation Text: Bohringer C. Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and…

  6. Organizational Learning | PSNet

    psnet.ahrq.gov/curated-library/organizational-learning
    November 10, 2025 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Organizational Learning  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet Team…

  7. Harnessing Health Information Technology for Self-Management Support and Medication Activation in a Medicaid Health Plan | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/harnessing-health-information-technology-self-management-support-and-medication
    January 01, 2023 - Harnessing Health Information Technology for Self-Management Support and Medication Activation in a Medicaid Health Plan Project Final Report ( PDF , 325.41 KB) Disclaimer Disclaimer The findings and conclusions in this document are those of the author(s), who are responsible f…

  8. The Unfinished Patient Safety Agenda | PSNet

    psnet.ahrq.gov/perspective/unfinished-patient-safety-agenda
    August 01, 2005 - The Unfinished Patient Safety Agenda Linda H. Aiken, PhD, RN | August 1, 2005  Also Read a Conversation View more articles from the same authors. Citation Text: Aiken LH. The Unfinished Patient Safety Agenda. PSNet [internet]. Rockville (MD): Agency for Healthc…

  9. Arcia-notes-Teresa (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/arcia-presentation.pdf
    October 08, 2025 - Arcia-notes-Teresa First, I'd like to acknowledge my colleagues, Dr. Sue Bakken is my mentor and   is the PI of one of the major projects I'll be talking about today. 1 And  here you  can  also see our funding sources. 2 Today I'm going to talk about some of the opportunities that technology crea…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867359/psn-pdf
    December 18, 2024 - is given to the wrong baby, there is a risk of transmission of infectious diseases to the baby as happened

  11. Standardized Simulated Events for Provocative Testing of Medical Care System Rescue Capabilities (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Blike.pdf
    January 01, 2003 - Standardized Simulated Events for Provocative Testing of Medical Care System Rescue Capabilities 193 Standardized Simulated Events for Provocative Testing of Medical Care System Rescue Capabilities George Blike, Joseph Cravero, Steve Andeweg, Jens Jensen, Klaus Christoffersen Abstract Background: Human er…

  12. TeamSTEPPS® Diagnosis Improvement: Module 1 Introduction

    www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module1-introduction.pptx
    January 12, 2022 - TeamSTEPPS® Diagnosis Improvement: Module 1 Introduction Module 1 Introduction TeamSTEPPS® for Diagnosis Improvement Welcome to the TeamSTEPPS for Diagnosis Improvement Course. This presentation will cover the introduction to the TeamSTEPPS for Diagnosis Improvement material that you will review with the course par…

  13. TeamSTEPPS® Diagnosis Improvement: Module 1 Introduction (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module1-presenters-notes.pdf
    January 12, 2022 - TeamSTEPPS® Diagnosis Improvement: Module 1 Introduction Slide 1 TeamSTEPPS® for Diagnosis Improvement                                                                                                                                                                                                               …

  14. Importance of Following Safe Practices for Infant Feeding and Handling Expressed Breast Milk | PSNet

    psnet.ahrq.gov/web-mm/importance-following-safe-practices-infant-feeding-and-handling-expressed-breast-milk
    January 31, 2024 - milk is given to the wrong baby, there is a risk of transmission of infectious diseases to the baby as happened

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73153/psn-pdf
    April 28, 2021 - To understand what happened in these two cases, and how to prevent such errors in the future, we must

  16. Puh-Implementation-Handouts (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-implementation-handouts.pdf
    July 01, 2016 - Do you remember what happened that day with your nursing assistants? … Nurse Manager A: No, I don’t remember what happened, but I’m not so sure it’s really necessary to have

  17. Improving-Facnotes (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/improving/improving-facnotes.docx
    May 01, 2017 - It gives the team a chance to make a plan for recovery and think about what happened during the procedure … Finally, there should be an opportunity to improve what happened in every case by asking and seeking

  18. Creative Strategies to Improving Patient Care Experience Webcast Transcript (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-creative-strategies-transcript.pdf
    April 01, 2019 - So there is some increase that happened there in patient experience as a result of the added-role approach … pages of typed notes that describe the creative improvement ideas that were discussed as well as what happened

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867676/psn-pdf
    February 26, 2025 - Responding to Patient Safety Events February 26, 2025 Shaikh U. Responding to Patient Safety Events. PSNet [internet]. 2025. https://psnet.ahrq.gov/primer/responding-patient-safety-events Background Patient safety events that occur in health care facilities require prompt action to ensure that further harm is mit…

  20. Using the AHRQ Medical Office Survey on Patient Safety Culture Webinar - Fagnan & Rollins (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/fagnan-reflections-perceptions-mosops.pdf
    June 02, 2025 - Using the AHRQ Medical Office Survey on Patient Safety Culture Webinar - Fagnan & Rollins Practice Reflections & Perceptions of MOSOPS—Process, Value, and Potential Use L.J. Fagnan, MD and Nancy Rollins Oregon Rural Practice-based Research Network (ORPRN) Oregon Health & Science University AHRQ PBRN Task Order…
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