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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/educational-agenda-diagnostic-error-reduction
February 27, 2019 - January 23, 2017
What happened to my patient?
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psnet.ahrq.gov/issue/lessons-health-care-leaders-rethinking-and-reinvesting-patient-safety
May 01, 2019 - Summary
July 23, 2024
Events that inspired change: the importance of sharing what 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/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/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/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/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/patient-safety/settings/long-term-care/resource/facilities/ltc/mod3sess3.html
October 01, 2014 - Most of the falls have happened at night after his private duty caregiver has gone home. … But even if you think a mistake may have happened, you must report the change.
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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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www.ahrq.gov/talkingquality/translate/scores/scoring.html
June 01, 2016 - Do you want to tell people how often this event happened or how often it did not happen?
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psnet.ahrq.gov/perspective/conversation-james-p-bagian-md-pe
February 26, 2025 - The way I would look at it is to try to understand what happened, why did it happen, and what do you … JB : W cubed: What happened? Why did it happen? … management have the courage to look a reporter in the eye and say, "First we need to understand what happened
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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/errors-otolaryngology-revisited
August 11, 2010 - May 17, 2023
Events that inspired change: the importance of sharing what happened to
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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/teaching-about-diagnostic-errors-through-virtual-patient-cases-pilot-exploration
September 18, 2013 - January 23, 2017
What happened to my patient?
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psnet.ahrq.gov/issue/child-health-pso-10-years-emerging-learning-network
July 28, 2021 - Related Resources
Events that inspired change: the importance of sharing what happened
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psnet.ahrq.gov/issue/girl-who-cried-pain-bias-against-women-treatment-pain
February 08, 2023 - It happened to me, as a pregnant OB-GYN.