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Total Results: 3,987 records

Showing results for "happened".

2601. Sustaining Zero CLABSIs (Transcript) | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/toolkit/content-calls/zero-clabsi.html
      April 01, 2013 - Sustaining Zero CLABSIs (Transcript) May 8, 2012 Operator: Excuse me, everyone, we now have our speakers in conference. Please be aware that each of your lines is currently in a listen-only mode. At the conclusion of the presentation, we will open the floor for questions, and at that time instructions will b…

2602. Playing Well with Others: "Translocational Research" in Patient Safety | PSNet
      psnet.ahrq.gov/perspective/playing-well-others-translocational-research-patient-safety
      September 01, 2005 - Playing Well with Others: "Translocational Research" in Patient Safety Robert M. Wachter, MD | September 1, 2005  Also Read a Conversation View more articles from the same authors. Citation Text: Wachter R. Playing Well with Others: "Translocational Research" in…

2603. The Safety of Medical Devices | PSNet
      psnet.ahrq.gov/perspective/safety-medical-devices
      June 01, 2011 - The Safety of Medical Devices Christopher Nemeth, PhD | June 1, 2011  Also Read a Conversation View more articles from the same authors. Citation Text: Nemeth CP. The Safety of Medical Devices. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and…

2604. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867656/psn-pdf
      February 26, 2025 - In Conversation with Lucy Savitz about Learning Health Systems for Patient Safety February 26, 2025 Savitz LA, Sousane Z, Mossburg SE. In Conversation with Lucy Savitz about Learning Health Systems for Patient Safety. PSNet [internet]. 2025. https://psnet.ahrq.gov/perspective/conversation-lucy-savitz-about-learnin…

2605. In Conversation with…Donald M. Berwick, MD, MPP | PSNet
      psnet.ahrq.gov/perspective/conversation-withdonald-m-berwick-md-mpp
      November 01, 2005 - In Conversation with…Donald M. Berwick, MD, MPP November 1, 2005  Also Read an Essay Citation Text: In Conversation with…Donald M. Berwick, MD, MPP. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Ser…

2606. In Conversation With… Vineet Chopra, MD, MSc | PSNet
      psnet.ahrq.gov/perspective/conversation-vineet-chopra-md-msc
      February 28, 2024 - In Conversation With… Vineet Chopra, MD, MSc October 30, 2019  Citation Text: In Conversation With… Vineet Chopra, MD, MSc. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation…

2607. Making Healthcare Safer IV: Programs for Responding to Harms Experienced by Patients during Clinical Care (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/clinical-care-protocol.pdf
      January 01, 2024 - Making Healthcare Safer IV: Programs for Responding to Harms Experienced by Patients during Clinical Care Evidence-based Practice Center Rapid Review Protocol Project Title: Making Healthcare Safer IV: Programs for Responding to Harms Experienced by Patients during Clinical Care Review Question…

2608. Patient Identification Errors: A Systems Challenge | PSNet
      psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge
      February 23, 2011 - Patient Identification Errors: A Systems Challenge Citation Text: Choudhury LS, Vu CT. Patient Identification Errors: A Systems Challenge. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: Googl…

2609. Chest Tube Complications | PSNet
      psnet.ahrq.gov/web-mm/chest-tube-complications
      September 27, 2023 - Chest Tube Complications Citation Text: Santhosh L, Broaddus C. Chest Tube Complications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…

2610. Adverse Events, Near Misses, and Errors | PSNet
      psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors
      March 30, 2022 - Adverse Events, Near Misses, and Errors Citation Text: Adverse Events, Near Misses, and Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 X…

2611. Final Progress Report: Leveraging Existing Assessments of Risk Now (LEARN) Final Report (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/woods2-report.pdf
      January 01, 2025 - Final Progress Report: Leveraging Existing Assessments of Risk Now (LEARN) Final Report Leveraging Existing Assessments of Risk Now (LEARN) Final Report PI: Donna Woods, EdM, PhD Jane Holl, MD, MPH; Sally Reynolds, MD; Robert Wears, MD; Ellen Schwalenstocker, PhD; Jonathan Young; O…

2612. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/853902/psn-pdf
      September 27, 2023 - It is not entirely clear what happened, but aggressive diuresis with concurrent diarrhea, possibly in

2613. Module 5: How To Measure Pressure Injury Rates and Prevention Practices | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/workshop/guide5.html
      October 01, 2017 - Ask: Has anyone here ever used root cause analysis to study why something happened and determine possible

2614. Executive Summary | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/summary.html
      August 01, 2022 - safety event occurred; what contributed to the event; whether or to whom an event was reported; what happened

2615. Two-Day Training Content | Agency for Healthcare Research and Quality
      www.ahrq.gov/teamstepps-program/curriculum/team/teach/two-day.html
      February 01, 2024 - participants for a story of when a patient was overlooked in a team decision that affected their care and what happened

2616. Summary of the Design Plan for the National Evaluation of the CHIPRA Quality Demonstration Grant Program (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/design_plan_for_chipra.pdf
      July 01, 2012 - questions about whether the CHIPRA funds actually made a difference or whether observed changes would have happened

2617. Module 5: How To Measure Pressure Injury Rates and Prevention Practices (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module5/module5_pu_measurement.docx
      January 01, 2016 - ASK: Has anyone here ever used root cause analysis to study why something happened and determine possible

2618. Final Design Plan for the National Evaluation of the CHIPRA Quality Demonstration Grant Program: Summary (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/finaldesignplan.pdf
      September 01, 2015 - about whether the CHIPRA funds actually made the difference or whether observed changes would have happened

2619. National Action Alliance to Advance Patient Safety Webinar Series (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/CMS-Aug-23-board-session.pdf
      August 22, 2023 - • Notified by management to the board in a timely manner as they happened?

2620. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865429/psn-pdf
      April 24, 2024 - Precipitating factors include direct irritation of atrial tissue by the venous cannula (as appears to have happened