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Total Results: 4,079 records

Showing results for "happened".

  1. Patients should know who's operating, surgeons say. | PSNet

    psnet.ahrq.gov/issue/patients-should-know-whos-operating-surgeons-say
    May 15, 2024 - October 9, 2024 Inside the preventable deaths that happened within a prominent transplant

  2. Session 1 | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mod2sess1.html
    October 01, 2014 - staff—benefits from an environment that supports discussion and learning from unwanted events that happened … or nearly happened.

  3. When a heart attack goes undiagnosed. | PSNet

    psnet.ahrq.gov/issue/when-heart-attack-goes-undiagnosed
    November 08, 2023 - It happened to me, as a pregnant OB-GYN.

  4. Far more could be done to stop the deadly bacteria C. diff. | PSNet

    psnet.ahrq.gov/issue/far-more-could-be-done-stop-deadly-bacteria-c-diff
    November 08, 2023 - It happened to me, as a pregnant OB-GYN.

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33877/psn-pdf
    April 01, 2019 - They were allowed to call a hotline number and report issues that had happened. … That is how physicians became engaged in notifying the organization about things that had happened. … about 16% of them will say anything empathically, anything along the lines of "I'm so sorry this has happened … You don't know the facts yet, but you do know something terrible has happened to her."

  6. The Texas Health Presbyterian Hospital Ebola Crisis: A Perfect Storm of Human Errors, System Failures and Lack of Mindfulness. | PSNet

    psnet.ahrq.gov/issue/texas-health-presbyterian-hospital-ebola-crisis-perfect-storm-human-errors-system-failures
    February 23, 2018 - This analysis of the incident breaks down what happened and explores how attention to mindfulness

  7. Canadian Incident Analysis Framework. | PSNet

    psnet.ahrq.gov/issue/canadian-incident-analysis-framework
    December 04, 2016 - gather insights from staff, patients, and family members regarding what caused the failure and why it happened

  8. Joshua’s Story. | PSNet

    psnet.ahrq.gov/issue/joshuas-story
    February 26, 2014 - The father's quest to understand what happened led to a comprehensive inquiry that revealed regulatory

  9. Cusp Patient Family Engagement Facilitator Notes (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/patfamilyengagement/CUSP_Patient_Family_Engagement_Facilitator_Notes.docx
    June 02, 2025 - critical, feedback, and focus on how to prevent a problem from reoccurring rather than focusing on what happened … Providers communicate the facts of what happened and assure the patient and family that they will receive … communicated to the patient and family: · An apology for any unreasonable care · An explanation of what happened … A hospital committed to transparency offers an apology that the incident happened.

  10. Snowball in a Blizzard: A Physician's Notes on Uncertainty in Medicine. | PSNet

    psnet.ahrq.gov/issue/snowball-blizzard-physicians-notes-uncertainty-medicine
    March 20, 2019 - Debriefing for Clinical Learning November 18, 2021 Deny, Dismiss, Dehumanise: What Happened

  11. Saving Moms. | PSNet

    psnet.ahrq.gov/issue/saving-moms
    April 26, 2023 - It happened to me, as a pregnant OB-GYN.

  12. Coming clean on medical mistakes. | PSNet

    psnet.ahrq.gov/issue/coming-clean-medical-mistakes
    February 20, 2019 - Here's how it happened.

  13. Faced with a drug shortfall, doctors scramble to treat children with cancer. | PSNet

    psnet.ahrq.gov/issue/faced-drug-shortfall-doctors-scramble-treat-children-cancer
    October 30, 2019 - How could it have happened?

  14. COVID-19 leads to increased need for dialysis machines. | PSNet

    psnet.ahrq.gov/issue/covid-19-leads-increased-need-dialysis-machines
    April 29, 2020 - July 10, 2024 Inside the preventable deaths that happened within a prominent transplant

  15. Uncovering the shocking dangers of misdiagnosis. | PSNet

    psnet.ahrq.gov/issue/uncovering-shocking-dangers-misdiagnosis
    May 13, 2020 - March 13, 2024 What Happened to Patient Safety.

  16. Alcohol Use Disorders Identification Test; (Seale et al 2006; Reinert et al 2007) (pdf file)

    integrationacademy.ahrq.gov/sites/default/files/2020-07/AUDIT.pdf
    January 01, 2020 - How often during the last year have you been unable to remember what happened the night

  17. Learning from Bristol: The Report of the Public Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary 1984--1995. | PSNet

    psnet.ahrq.gov/issue/learning-bristol-report-public-inquiry-childrens-heart-surgery-bristol-royal-infirmary-1984
    October 20, 2021 - Their objectives included understanding what happened in Bristol, assessing the quality of care and system

  18. CAHPS End of Life Care Survey (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/end-of-life/end-of-life-care-survey-english.pdf
    December 03, 2024 - Please explain what happened, where it happened, and how it felt to you and/or your family member.

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33670/psn-pdf
    July 01, 2008 - So there's no way of knowing what has happened. … And this happened after a lengthy root cause analysis, which took perhaps 100 hours to perform. … And at every meeting, the board should also track what had happened to the previous quarter's or previous … year's root cause analyses and recommendations, and again, if possible, what has happened to that kind

  20. Simulation Facguide (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/situ/simulation_facguide.docx
    May 01, 2017 - 16 SAY: The debrief process usually involves four steps: introducing the process, describing what happened … Slide 17 SAY: The next step in the debrief process is to describe what happened. … In discussing why things happened in the scenario as they did, the team should focus on critical aspects … They can explain how and why certain outcomes may have happened “Was the decision made right (correctly
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