-
psnet.ahrq.gov/issue/physician-liability-age-data-reliance-and-errors
March 18, 2020 - March 18, 2020
Medication mix-up: what happened at Vanderbilt and how it impacts health
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psnet.ahrq.gov/issue/next-generation-doctors-may-be-learning-bad-habits-teaching-hospitals-many-safety-violations
June 28, 2023 - Related Resources From the Same Author(s)
Inside the preventable deaths that happened
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psnet.ahrq.gov/issue/doctor-gave-me-inept-diagnosis-neurological-problem-i-should-know-im-neurologist
April 27, 2022 - It happened to me, as a pregnant OB-GYN.
April 26, 2023
The prisoner.
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psnet.ahrq.gov/issue/how-columbia-ignored-women-undermined-prosecutors-and-protected-predator-more-20-years
May 31, 2023 - August 16, 2023
Inside the preventable deaths that happened within a prominent transplant
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psnet.ahrq.gov/issue/demanding-medical-excellence-doctors-and-accountability-information-age
May 13, 2020 - December 9, 2020
Deny, Dismiss, Dehumanise: What Happened When I Went to Hospital.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Borowitz_4.pdf
January 22, 2008 - the patients on the wards
during the night shift meet with other members of the team to review what happened … Resident physicians indicated that something happened while they were on call for which they
were not … baseline assessment, the
residents indicated that in 40 of the 49 (82 percent) instances that something happened … During
the baseline assessment and after the intervention, sign-outs for nights when something happened … on nearly one-third of the nights they were on call, resident
physicians indicated that something happened
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/162-example-completed-learning-defects-tool.docx
October 01, 2024 - Provide a clear, thorough, and objective explanation of what happened.
II. … What happened? In the space below, identify the MRSA infection or other event.
-
www.ahrq.gov/hai/cusp/modules/understand/science-safety-notes.html
July 01, 2018 - When learning from defects, unit 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?
Why did it happen?
How will you reduce the risk of recurrence?
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/situ/simulation_facguide.pdf
May 01, 2017 - SAY:
The debrief process usually involves four
steps: introducing the process, describing
what happened … Program
of In Situ Simulations 11
SAY:
The next step in the debrief process is to
describe what happened … In discussing why things happened in the
scenario as they did, the team should focus on
critical aspects … They can explain how and why
certain outcomes may have happened
“Was the decision made right (correctly
-
psnet.ahrq.gov/issue/language-discordance-and-patient-care-babel
October 30, 2024 - It happened to me, as a pregnant OB-GYN.
-
psnet.ahrq.gov/issue/life-mother-how-abortion-bans-lead-preventable-deaths
October 02, 2024 - It happened to me, as a pregnant OB-GYN.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/medical-office/resources/infotransMOSOPS.pdf
January 01, 2010 - (NOTE: This question asks about things that happened in
the past – should use past tense, not present … accurate,
complete, and timely information with:
(NOTE: This question also asks about things that happened
-
www.ahrq.gov/sops/international/medical-office/translators.html
January 01, 2010 - ( Note: This question asks about things that happened in the past—should use past tense, not present … accurate, complete, and timely information with: ( Note: This question also asks about things that happened
-
psnet.ahrq.gov/node/33648/psn-pdf
March 01, 2007 - After we signed the legal papers, I called Rick Kidwell, the lawyer at Hopkins, and said, "What
happened … They're great things that happened. That
makes me really happy.
-
www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-3.html
June 01, 2023 - their safety concerns did so through a sequence of open-ended questions 18 :
Please tell us what happened … Considering only respondents for whom the diagnostic problem happened 3 or more years in the past, 28 … clinicians, scaffolding questions asked about these encounters and encouraged respondents to “explain what happened … , how it happened, and how it felt to you.”
-
psnet.ahrq.gov/issue/first-do-less-harm-confronting-inconvenient-problems-patient-safety
March 29, 2007 - October 18, 2017
The Emperor’s New Clothes: Or Whatever Happened To “Human Error”?
-
psnet.ahrq.gov/issue/when-healthcare-hurts
January 15, 2014 - August 1, 2012
Deny, Dismiss, Dehumanise: What Happened When I Went to Hospital.
-
psnet.ahrq.gov/issue/robotic-assisted-surgery-focus-training-and-credentialing
January 07, 2015 - View More
Related Resources
Inside the preventable deaths that happened
-
psnet.ahrq.gov/issue/why-doctors-still-offer-treatments-may-not-help
July 20, 2016 - How could it have happened?
-
psnet.ahrq.gov/issue/first-protect-patient-harm-applying-adult-learning-principles-patient-safety
June 09, 2011 - How could it have happened?