Results

Total Results: 4,082 records

Showing results for "happened".

261. 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

262. 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.

263. 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.

264. 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.

265. 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."

266. 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

267. CommonSpirit Health Expands CANDOR Toolkit Across Entire Health System | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/202104.html
     October 01, 2021 - adverse event, and officials estimate 85 patients were spared the additional harm of not knowing what happened

268. 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

269. 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.

270. 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

271. 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

272. 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

273. 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

274. 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

275. 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.

276. 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.

277. 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?

278. Unwell Women: Misdiagnosis and Myth in a Man-Made World. | PSNet
     psnet.ahrq.gov/issue/unwell-women-misdiagnosis-and-myth-man-made-world
     March 20, 2019 - It happened to me, as a pregnant OB-GYN.

279. Amid COVID-19, discipline against bad doctors plummets; more medical errors may slip through cracks. | PSNet
     psnet.ahrq.gov/issue/amid-covid-19-discipline-against-bad-doctors-plummets-more-medical-errors-may-slip-through
     June 24, 2020 - It happened to me, as a pregnant OB-GYN.

280. 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?