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Showing results for "happened".

3541. Beyond the Pandemic: Creating Total Systems Safety | PSNet
      psnet.ahrq.gov/perspective/beyond-pandemic-creating-total-systems-safety
      August 30, 2023 - Beyond the Pandemic: Creating Total Systems Safety Patricia McGaffigan, MS, RN, CPPS; Cindy Manaoat Van, MHSA, CPPS; Sarah E. Mossburg, RN, PhD | August 30, 2023  Also Read the Conversation View more articles from the same authors. Citation Text: Van CM, Mossb…

3542. Planning and Implementing the Patient Advocacy Reporting System in the Sanford Health System | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/liability/pichert.html
      August 01, 2017 - Advances in Patient Safety and Medical Liability Planning and Implementing the Patient Advocacy Reporting System in the Sanford Health System Previous Page Next Page Table of Contents Advances in Patient Safety and Medical Liability Preface Acknowledgments Prologue Silence A Commentary Ref…

3543. Patient, Family Member, and Clinician Perceptions of Disclosure of Adverse Events in Labor and Delivery | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/liability/baker.html
      August 01, 2017 - Advances in Patient Safety and Medical Liability Patient, Family Member, and Clinician Perceptions of Disclosure of Adverse Events in Labor and Delivery Previous Page Next Page Table of Contents Advances in Patient Safety and Medical Liability Preface Acknowledgments Prologue Silence A Comme…

3544. The PRIDx framework to engage payers in reducing diagnostic errors in healthcare (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/topics/pridx-framework.pdf
      July 05, 2023 - The PRIDx framework to engage payers in reducing diagnostic errors in healthcare Mini Review Kisha J. Ali*, Christine A. Goeschel, Derek M. DeLia, Leah M. Blackall and Hardeep Singh The PRIDx framework to engage payers in reducing diagnostic errors in healthcare https://doi.org/10.1515/dx-2023-0042 Received April 9…

3545. Do Transient Working Conditions Trigger Medical Errors? (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Grayson.pdf
      January 01, 2003 - Do Transient Working Conditions Trigger Medical Errors? 53 Do Transient Working Conditions Trigger Medical Errors? Deborah Grayson, Stuart Boxerman, Patricia Potter, Laurie Wolf, Clay Dunagan, Gary Sorock, Bradley Evanoff Abstract Objective: Organizational factors affecting working conditions for health …

3546. In Conversation with... Christie Allen about Maternal Safety and Perinatal Mental Health | PSNet
      psnet.ahrq.gov/perspective/conversation-christie-allen-about-maternal-safety-and-perinatal-mental-health
      March 29, 2023 - In Conversation with... Christie Allen about Maternal Safety and Perinatal Mental Health March 28, 2023  Also Read the Essay Citation Text: In Conversation with.. Christie Allen about Maternal Safety and Perinatal Mental Health. PSNet [internet]. 2023.In Conversat…

3547. Final Progress Report: Patient Safety Learning Laboratory to Enhance the Value and Safety of Neonatal Interfacility Transfers in a Regional Care Network (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/umoren-report.pdf
      January 01, 2025 - Final Progress Report: Patient Safety Learning Laboratory to Enhance the Value and Safety of Neonatal Interfacility Transfers in a Regional Care Network Patient Safety Learning Laboratory to Enhance the Value and Safety of Neonatal Interfacility Transfers in a Regional Care Network Rachel A. Umoren, MBBCh, MS Mega…

3548. Clinical Decision Support for Chronic Pain Management - Executive Summary (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/cds4cpm-executive-summary-2024.pdf
      January 01, 2024 - Clinical Decision Support for Chronic Pain Management - Executive Summary Clinical Decision Support for Chronic Pain Management Executive Summary Prepared for Agency for Healthcare Research and Quality 5600 Fishers Lane Rockville, MD 20857 Prepared by Laura Haak Marcial, PhD Sara Jacobs, PhD Son…

3549. Creating a Culture of Patient Safety through Innovative Hospital Design (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Reiling.pdf
      January 01, 2004 - Creating a Culture of Patient Safety through Innovative Hospital Design 425 Creating a Culture of Patient Safety through Innovative Hospital Design John G. Reiling Abstract When SynergyHealth, St. Joseph’s Hospital of West Bend, Wisconsin, decided to relocate and build an 82-bed acute care facility, we reco…

3550. Outpatient Surgery and Patient Safety—The Patient’s Voice (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Hundt.pdf
      January 01, 2003 - Outpatient Surgery and Patient Safety—The Patient’s Voice 445 Outpatient Surgery and Patient Safety— The Patient’s Voice Ann Schoofs Hundt, Pascale Carayon, Scott Springman, Maureen Smith, Kelly Florek, Rupa Sheth, Margaret Dorshorst Abstract Four outpatient surgery centers from a large Midwestern communit…

3551. Failure Modes and Effects Analysis Based on In Situ Simulations: A Methodology to Improve Understanding of Risks and Failures (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Davis_60.pdf
      April 07, 2008 - Failure Modes and Effects Analysis Based on In Situ Simulations: A Methodology to Improve Understanding of Risks and Failures Failure Modes and Effects Analysis Based on In Situ Simulations: A Methodology to Improve Understanding of Risks and Failures Stanley Davis, MD; William Riley, PhD; Ayse P. Gurses, PhD; Kr…

3552. Improving Clinical Communication and Patient Safety: Clinician-Recommended Solutions (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Woods_78.pdf
      July 23, 2008 - Improving Clinical Communication and Patient Safety: Clinician-Recommended Solutions Improving Clinical Communication and Patient Safety: Clinician-Recommended Solutions Donna M. Woods, EdM, PhD; Jane L. Holl, MD, MPH; Denise Angst, PhD, RN; Susan C. Echiverri, MD; Daniel Johnson, MD; David F. Soglin, MD; Gop…

3553. In Conversation with... Patricia McGaffigan about Beyond the Pandemic: Creating Total Systems Safety | PSNet
      psnet.ahrq.gov/perspective/conversation-patricia-mcgaffigan-about-beyond-pandemic-creating-total-systems-safety
      August 30, 2023 - In Conversation with... Patricia McGaffigan about Beyond the Pandemic: Creating Total Systems Safety Patricia McGaffigan, MS, RN, CPPS; Cindy Manaoat Van, MHSA, CPPS; Sarah E. Mossburg, RN, PhD | August 30, 2023  Also Read the Essay View more articles from the same authors. …

3554. Obesity Prevention and Control (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/pdf/obesity-research-methods_research-protocol.pdf
      February 08, 2017 - composition changing over time; Comparison group not providing accurate estimate of what would have happened

3555. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60241/psn-pdf
      February 24, 2022 - Given that this happened in April and May 2020 when staff lacked the knowledge about asymptomatic spread

3556. Context-Aware Knowledge Delivery into Electronic Health Records - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/k01hs018352-del-fiol-final-report-2013.pdf
      January 01, 2013 - capabilities to be included in the United States Meaningful Use Certification Criteria EHR systems (this happened

3557. Surveillance for Adverse Drug Events in Ambulatory Pediatrics (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/r18hs017010-bailey-final-report-2011.pdf
      January 01, 2011 - Incidental signals were those that happened to be detected by the pharmacist when they were prompted

3558. Final Progress Report: What About Mom? Using Administrative Data To Develop Measures for Monitoring Healthcare Quality in Pregnancy & Childbirth (pdf file)
      www.ahrq.gov/sites/default/files/2024-11/gregory-report.pdf
      January 01, 2024 - code used only in MDC 14), this is likely to be listed as the principal diagnosis, even though it happened

3559. Toolkit for Reducing CAUTI in Hospital Units: Implementation Guide (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/impl-guide/implementation-guide.pdf
      September 01, 2015 - CAUTI is identified, the staff are more likely to take note and become interested in knowing what happened

3560. Final Progress Report: Implementing a Program of Patient Safety in Small, Rural Hospitals (pdf file)
      www.ahrq.gov/sites/default/files/2024-02/jones-report.pdf
      January 01, 2024 - the language of errors associated with MEDMARX, all we could talk about was who did it and not what happened