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Total Results: 3,974 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. The fading art of the physical exam. | PSNet

    psnet.ahrq.gov/issue/fading-art-physical-exam
    July 10, 2024 - August 28, 2019 Deny, Dismiss, Dehumanise: What Happened When I Went to Hospital.

  3. 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.

  4. Resilience Engineering in Practice: a Guidebook. | PSNet

    psnet.ahrq.gov/issue/resilience-engineering-practice-guidebook
    February 06, 2019 - respond to disruptions , monitor their environment, anticipate future impacts, and learn from what happened

  5. 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

  6. 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

  7. 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

  8. 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

  9. 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?

  10. 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.

  11. 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.

  12. 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

  13. 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

  14. 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.

  15. Saving Moms. | PSNet

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

  16. Building Capacity for Patient Safety | PSNet

    psnet.ahrq.gov/perspective/building-capacity-patient-safety
    July 31, 2023 - Based on that event, we were able to alert healthcare workers about what happened to bring attention … You need a feedback loop built into the system to share what happened and what the organization is doing … Being able to take what happened and share those stories across different settings is helpful. … We receive 300,000 reports a year but do not often get information on why something happened or how it … happened.

  17. In Conversation with... Regina Hoffman about Building Capacity for Patient Safety | PSNet

    psnet.ahrq.gov/perspective/conversation-regina-hoffman-about-building-capacity-patient-safety
    July 31, 2023 - Based on that event, we were able to alert healthcare workers about what happened to bring attention … You need a feedback loop built into the system to share what happened and what the organization is doing … Being able to take what happened and share those stories across different settings is helpful. … We receive 300,000 reports a year but do not often get information on why something happened or how it … happened.

  18. In Conversation With… Timothy B. McDonald, MD, JD | PSNet

    psnet.ahrq.gov/perspective/conversation-timothy-b-mcdonald-md-jd
    February 26, 2025 - 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."

  19. Changing-System-Facilitator-Guide (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-facilitator-guide.docx
    June 01, 2021 - A simple way to put this approach into action is by asking four questions: · What happened? … Slide 12 What Happened? SAY: Let’s first consider what happened to our resident.

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33688/psn-pdf
    October 01, 2009 - A couple of things happened in the summer of 2003 that caused us to focus on King/Drew. … RW: You mentioned that there was a second thing that happened? … Then, not only is the problem what actually happened, but the problem is that you tried to cover it … mistake was made, patients may have died, and the key thing is to be honest about it, explain how it happened … RW: If a hospital that had the same deficiencies and the same Joint Commissioner or state reports happened
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