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psnet.ahrq.gov/issue/report-focuses-risk-patients-ed-errors
June 26, 2019 - It happened to me, as a pregnant OB-GYN.
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psnet.ahrq.gov/issue/prescription-disaster-americas-broken-pharmacy-system-revolt-over-burnout-and-errors
May 17, 2023 - It happened to me, as a pregnant OB-GYN.
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psnet.ahrq.gov/issue/made-whole-efficacy-legal-redress-black-women-who-have-suffered-injuries-medical-bias
February 23, 2022 - May 17, 2023
Medication mix-up: what happened at Vanderbilt and how it impacts health
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psnet.ahrq.gov/issue/does-malpractice-liability-make-healthcare-safer-aligning-law-and-policy-evidence
August 26, 2020 - June 2, 2021
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Related Resources
Medication mix-up: what happened
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psnet.ahrq.gov/issue/crisis-lakeshore-hospital-er
March 15, 2022 - Patient Safety Initiatives
July 10, 2024
Inside the preventable deaths that happened
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/situ/sim-tool-guidance.html
July 01, 2023 - team members gain insight into one another's perspective, helps the team to reach consensus on what happened … Push the team to go beyond just describing what happened.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cusp-icu-slides.pptx
April 01, 2022 - Defects13
1
2
3
4
AHRQ Safety Program for ICUs: Preventing CLABSI and CAUTI
Applying CUSP ׀ 13
What happened … AHRQ Safety Program for ICUs: Preventing CLABSI and CAUTI
Applying CUSP ׀ 14
Understand Why Defect Happened
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psnet.ahrq.gov/issue/jama-professionalism-disclosure-medical-error
December 19, 2018 - Recommended best practices for error disclosure include being honest about what happened, explicitly
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/training-tools/success-transcript.html
June 01, 2017 - use the checklist and ask about it, we decided to put up a bulletin board in the break room, which happened
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psnet.ahrq.gov/issue/abandon-term-second-victim
October 09, 2024 - May 22, 2019
Deny, Dismiss, Dehumanise: What Happened When I Went to Hospital.
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psnet.ahrq.gov/issue/respectful-trusting-relationships-are-essential-patient-safety-especially-surgeon
December 08, 2024 - How could it have happened?
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psnet.ahrq.gov/node/33686/psn-pdf
August 01, 2009 - Similar to
what happened in Boston, a bunch of people stood up and said, "Well, we've tried everything … Why do you think the problem
happened? What can we do to help?" … proves to be a difficult problem, are part of the constant experimentation to discover why the
problem happened … How could that have happened?" … don't avoid meeting the patient's needs but call attention to the
problem so we can understand why it happened
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psnet.ahrq.gov/issue/machine-learning-medicine
March 13, 2024 - March 11, 2011
What happened to my patient?
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psnet.ahrq.gov/web-mm/intraoperative-awareness-during-rhinoplasty
January 29, 2021 - and embarrassed that the patient remembered waking up during the operation but could not explain what happened … Details of what is recalled should be elicited and compared with what happened during the operation. … It is therefore very important to review the anesthetic record to understand what happened. … It will be obvious if the patient truly remembers things that happened during the procedure.
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psnet.ahrq.gov/issue/medical-errors-still-claiming-many-lives
September 19, 2007 - It happened to me, as a pregnant OB-GYN.
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psnet.ahrq.gov/issue/when-doctors-get-it-wrong-misdiagnoses-are-getting-closer-look
October 24, 2012 - Here's how it happened.
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psnet.ahrq.gov/issue/whistle-blowing-nurse-acquitted-texas
May 28, 2008 - How could it have happened?
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psnet.ahrq.gov/issue/patient-stories-2013-time-change
November 14, 2011 - 2013
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Related Resources
Deny, Dismiss, Dehumanise: What Happened
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psnet.ahrq.gov/issue/girl-dies-during-restraint-hospital-already-criticized-problems
March 16, 2011 - October 25, 2023
Inside the preventable deaths that happened within a prominent transplant
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psnet.ahrq.gov/issue/using-web-or-app-instead-seeing-doctor-caution-advised
December 16, 2015 - How could it have happened?