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Total Results: 3,974 records

Showing results for "happened".

  1. Specific Barriers and Challenges to Reporting and Learning From Diagnostic Errors | Agency for Healthcare Research and Quality

    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-psychological-safety-3.html
    September 01, 2023 - The conclusion that an error happened at all might depend on the reviewer’s perspective; in fact, consensus

  2. Strengthening open disclosure in maternity services in the English NHS: the DISCERN realist evaluation study. | PSNet

    psnet.ahrq.gov/issue/strengthening-open-disclosure-maternity-services-english-nhs-discern-realist-evaluation-study
    April 12, 2023 - Following adverse events, many patients and families welcome disclosure from their providers about what happened

  3. Safety II behavior in a pediatric intensive care unit. | PSNet

    psnet.ahrq.gov/issue/safety-ii-behavior-pediatric-intensive-care-unit
    January 12, 2022 - frequently referred to as Safety-I , involved responding to adverse events and near misses after they happened

  4. Identifying Adverse Events Not Present on Admission: Can We Do It? | PSNet

    psnet.ahrq.gov/perspective/identifying-adverse-events-not-present-admission-can-we-do-it
    October 01, 2008 - That was appropriate when the adverse events just happened and they cost institutions more money to take … So if the hospital is going to be tagged with an adverse event that happened at another place, that's … advance directives and other elements of complex care that take time, where the metric of whether it happened … Under the old payment system, when the adverse event happened, the hospital would get paid an extra 50% … And I think that's happened.

  5. Every error a treasure: improving medication use with a nonpunitive reporting system. | PSNet

    psnet.ahrq.gov/issue/every-error-treasure-improving-medication-use-nonpunitive-reporting-system
    August 17, 2016 - describe the implementation of a nonpunitive reporting system at their hospital and the improvements that happened

  6. The glaring loophole in U.S. virus response: human error. | PSNet

    psnet.ahrq.gov/issue/glaring-loophole-us-virus-response-human-error
    March 18, 2020 - View More Related Resources Inside the preventable deaths that happened

  7. Use systems redesign and the law to prevent medical errors and accidents. | PSNet

    psnet.ahrq.gov/issue/use-systems-redesign-and-law-prevent-medical-errors-and-accidents
    August 26, 2020 - July 19, 2023 Inside the preventable deaths that happened within a prominent transplant

  8. Doctors wrestle with A.I. in patient care, citing lax oversight. | PSNet

    psnet.ahrq.gov/issue/doctors-wrestle-ai-patient-care-citing-lax-oversight
    August 09, 2023 - How could it have happened?

  9. The APSF: 20-year anniversary of the first patient safety organization: past, present & future. | PSNet

    psnet.ahrq.gov/issue/apsf-20-year-anniversary-first-patient-safety-organization-past-present-future
    October 26, 2022 - Here's how it happened.

  10. The pain was unbearable. So why did doctors turn her away? | PSNet

    psnet.ahrq.gov/issue/pain-was-unbearable-so-why-did-doctors-turn-her-away
    November 25, 2020 - Here's how it happened.

  11. Fault Tree Analysis | Digital Healthcare Research

    digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/fault-tree-analysis
    January 01, 2023 - To identify causes of a failure after it has happened.

  12. The wrong foot, and other tales of surgical error. | PSNet

    psnet.ahrq.gov/issue/wrong-foot-and-other-tales-surgical-error
    January 18, 2023 - How could it have happened?

  13. Phony diagnoses hide high rates of drugging at nursing homes. | PSNet

    psnet.ahrq.gov/issue/phony-diagnoses-hide-high-rates-drugging-nursing-homes
    December 22, 2021 - How could it have happened?

  14. Antifatness in the surgical setting. | PSNet

    psnet.ahrq.gov/issue/antifatness-surgical-setting
    October 12, 2022 - Equity in Patient Safety March 27, 2024 Inside the preventable deaths that happened

  15. Doctors were alarmed: would I have my children have surgery here? | PSNet

    psnet.ahrq.gov/issue/doctors-were-alarmed-would-i-have-my-children-have-surgery-here
    February 19, 2020 - How could it have happened?

  16. TeamSTEPPS® Diagnosis Improvement: Diagnostic Journey of Mr. Kane (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/dx-journey-presenter-notes.pdf
    June 02, 2025 - We are still trying to make sense of everything that happened… Slide 5 Background – Joe Kane … This had happened a few times before as well and usually he would go to see Dr. … he had missed a few dialysis appointments, which resulted in the excess fluid, and that this had happened … that he had missed a few dialysis appointments, which resulted in the excess fluid, and that this had happened

  17. Journey of Mr. Kane

    www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/dx-journey-mr-kane.pptx
    June 02, 2025 - We are still trying to make sense of everything that happened… 4 Slide Background – Joe Kane 49-year-old … This had happened a few times before as well and usually he would go to see Dr. … that he had missed a few dialysis appointments, which resulted in the excess fluid, and that this had happened … that he had missed a few dialysis appointments, which resulted in the excess fluid, and that this had happened

  18. Debriefing for Clinical Learning | PSNet

    psnet.ahrq.gov/primer/debriefing-clinical-learning
    September 15, 2024 - When a person asks, “What happened?” they are initiating the process of debriefing. … What happened last night? Nurse JA is the clinical nurse supervisor on a trauma unit. … JA has a list of personnel who were present and wants to find out what happened, why it happened, and

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33594/psn-pdf
    November 18, 2021 - When a person asks, “What happened?” they are initiating the process of debriefing. … What happened last night? Nurse JA is the clinical nurse supervisor on a trauma unit. … psnet.ahrq.gov/primer/root-cause-analysis has a list of personnel who were present and wants to find out what happened … , why it happened, and how to prevent a similar event from happening ever again.

  20. Understanding CAHPS® Surveys: A Primer for New Users (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-patient-experience-fry-webinar.pdf
    January 01, 2014 - patient reports  Whether something that should happen actually did happen, and how often it happened
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