-
psnet.ahrq.gov/issue/nurses-seek-reduce-long-hours-and-fatigue
March 08, 2019 - It happened to me, as a pregnant OB-GYN.
-
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
-
psnet.ahrq.gov/issue/doctors-wrestle-ai-patient-care-citing-lax-oversight
August 09, 2023 - How could it have happened?
-
psnet.ahrq.gov/issue/glaring-loophole-us-virus-response-human-error
March 18, 2020 - View More
Related Resources
Inside the preventable deaths that happened
-
psnet.ahrq.gov/issue/phony-diagnoses-hide-high-rates-drugging-nursing-homes
December 22, 2021 - How could it have happened?
-
psnet.ahrq.gov/issue/antifatness-surgical-setting
October 12, 2022 - Equity in Patient Safety
March 27, 2024
Inside the preventable deaths that happened
-
psnet.ahrq.gov/issue/apsf-20-year-anniversary-first-patient-safety-organization-past-present-future
October 26, 2022 - Here's how it happened.
-
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
-
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.
-
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.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/esrd/using-checklists/checklistandauditslides.pptx
September 03, 2014 - When learning from defects, teams identify:
What happened?
Why did it happen? … Analyzing what happened and why it happened helps the team understand the contributing factors and processes … What happened?
Step 1. Reconstruct the timeline to understand what happened.
Step 2. … What happened?
2. Why did it happen?
3. What will you do to reduce the risk of recurrence?
4.
-
psnet.ahrq.gov/issue/these-patients-had-lobby-correct-diabetes-diagnoses-was-their-race-reason
July 10, 2024 - It happened to me, as a pregnant OB-GYN.
-
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
-
psnet.ahrq.gov/perspective/conversation-withkaveh-g-shojania-md
September 01, 2011 - you wouldn't want to do the whole aviation style, let's get the black box and find out exactly what happened … Because otherwise, you'll never really find out what happened and any resulting root cause analysis will … We know that it's very difficult to track down what's happened if weeks to months have gone by. … , and if you can identify them 6 months later, they're probably not going to remember a lot of what happened … They just want to let somebody know that something important happened, and if somebody in a position
-
psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please
September 01, 2011 - you wouldn't want to do the whole aviation style, let's get the black box and find out exactly what happened … Because otherwise, you'll never really find out what happened and any resulting root cause analysis will … We know that it's very difficult to track down what's happened if weeks to months have gone by. … , and if you can identify them 6 months later, they're probably not going to remember a lot of what happened … They just want to let somebody know that something important happened, and if somebody in a position
-
psnet.ahrq.gov/issue/why-false-positives-merit-concern-too
February 19, 2010 - How could it have happened?
October 30, 2019
My human doctor.
-
psnet.ahrq.gov/issue/patient-safety-supplement
November 01, 2012 - April 30, 2008
The Emperor’s New Clothes: Or Whatever Happened To “Human Error”?
-
psnet.ahrq.gov/issue/simulation-healthcare
November 23, 2014 - March 27, 2005
The Emperor’s New Clothes: Or Whatever Happened To “Human Error”?
-
psnet.ahrq.gov/issue/death-boy-prompts-new-medical-efforts-nationwide
March 22, 2014 - How could it have happened?
-
psnet.ahrq.gov/issue/healthcare-industry-representatives-maximizing-benefits-and-reducing-risks
March 18, 2010 - September 20, 2023
Inside the preventable deaths that happened within a prominent transplant