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psnet.ahrq.gov/issue/set-phasers-stun-and-other-true-tales-design-technology-and-human-error-second-edition
May 30, 2019 - Creating a Safer Workplace
October 31, 2023
Deny, Dismiss, Dehumanise: What Happened
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digital.ahrq.gov/ahrq-funded-projects/past-initiatives/privacy-and-security-project/alaska
January 01, 2023 - It will also prevent the loss of critical health records, as happened in 2005 because of hurricane Katrina
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psnet.ahrq.gov/issue/amid-lack-accountability-bias-maternity-care-california-family-seeks-justice
September 06, 2023 - It happened to me, as a pregnant OB-GYN.
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psnet.ahrq.gov/issue/role-racism-core-patient-safety-issue
March 18, 2020 - It happened to me, as a pregnant OB-GYN.
April 26, 2023
Saving Moms.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/recognizing-success-transcript.docx
May 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/simulation-based-trial-surgical-crisis-checklists
July 25, 2011 - available, and 97% of participants reported that they would want the checklist used if one of these crises happened
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psnet.ahrq.gov/issue/partnering-improve-quality-and-safety-framework-working-patient-and-family-advisors
July 01, 2015 - June 12, 2019
Deny, Dismiss, Dehumanise: What Happened When I Went to Hospital.
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psnet.ahrq.gov/issue/perchance-think
December 08, 2016 - April 10, 2019
WebM&M Cases
What Happened on Telemetry
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psnet.ahrq.gov/issue/disclosure-through-our-eyes
July 02, 2009 - June 26, 2019
Deny, Dismiss, Dehumanise: What Happened When I Went to Hospital.
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psnet.ahrq.gov/issue/after-roe-challenges-provision-lifesaving-care
September 23, 2015 - It happened to me, as a pregnant OB-GYN.
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psnet.ahrq.gov/issue/top-penn-state-health-surgeon-warned-leaders-about-transplant-problems-months-shutdown-then
July 18, 2018 - September 20, 2023
Inside the preventable deaths that happened within a prominent transplant
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psnet.ahrq.gov/issue/medical-mistakes-are-more-likely-women-and-minorities
November 01, 2017 - It happened to me, as a pregnant OB-GYN.
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psnet.ahrq.gov/issue/monitoring-diagnostic-process-inpatient-neurology-service
November 03, 2015 - January 23, 2017
What happened to my patient?
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psnet.ahrq.gov/issue/associations-between-hospitalist-shift-busyness-diagnostic-confidence-and-resource
September 16, 2020 - October 13, 2018
View More
Related Resources
“I had no idea this happened
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/situ/simtool_guidance.docx
May 01, 2017 - team members gain insight into one another's perspective, helps the team to reach consensus on what happened … factors that enabled or impeded the team's success.
· Push the team to go beyond just describing what happened
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psnet.ahrq.gov/perspective/conversation-michael-cohen-rph-ms-scd-hon-0
October 24, 2021 - We thought for sure that many errors that might have happened in the past wouldn't happen. … conversation between the pharmacist and the patient, a lot of errors that we saw in the past would not have happened … If you go to our website, it's very easy—just tell us what happened. … When I need reports regarding how many of this happened, they do that for me.
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psnet.ahrq.gov/issue/weekend-versus-weekday-admission-and-mortality-myocardial-infarction
February 18, 2011 - More
Related Resources
WebM&M Cases
What Happened
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psnet.ahrq.gov/issue/covid-19-delaying-routine-care-chronic-disease-startups-brace-slew-complications
May 02, 2018 - It happened to me, as a pregnant OB-GYN.
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psnet.ahrq.gov/issue/do-some-surgical-implants-do-more-harm-good
January 14, 2011 - View More
Related Resources
Inside the preventable deaths that happened
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psnet.ahrq.gov/issue/errors-otolaryngology-revisited
August 11, 2010 - May 17, 2023
Events that inspired change: the importance of sharing what happened to