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Total Results: 3,974 records

Showing results for "happened".

981. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39923/psn-pdf
     September 03, 2014 - Sued for misdiagnosis? It could happen to you. September 3, 2014 Lippman H, Davenport J. Sued for misdiagnosis? It could happen to you. J Fam Pract. 2010;59(9):498-508. https://psnet.ahrq.gov/issue/sued-misdiagnosis-it-could-happen-you This article explains how to avoid diagnostic error, minimize litigation, and pr…

982. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45874/psn-pdf
     February 22, 2017 - Ethics in the pediatric emergency department: when mistakes happen: an approach to the process, evaluation, and response to medical errors. February 22, 2017 Dreisinger N, Zapolsky N. Ethics in the Pediatric Emergency Department: When Mistakes Happen: An Approach to the Process, Evaluation, and Response to Medical…

983. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40194/psn-pdf
     June 20, 2011 - What happens when things go wrong? June 20, 2011 Brandom BW, Callahan P, Micalizzi DA. What happens when things go wrong? Paediatr Anaesth. 2011;21(7):730-6. doi:10.1111/j.1460-9592.2010.03513.x. https://psnet.ahrq.gov/issue/what-happens-when-things-go-wrong This commentary reveals a personal story of loss and dis…

984. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38215/psn-pdf
     November 14, 2011 - Could it happen here? Learning from other organizations' safety errors. November 14, 2011 Conway JB. Could it happen here? Learning from other organizations' safety errors. Healthcare Executive. 2008;23(6):64, 66-67. https://psnet.ahrq.gov/issue/could-it-happen-here-learning-other-organizations-safety-errors This…

985. Module 2: Example (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/huddles/example-pdsa-form.docx
     May 01, 2017 - Module 2: Example AHRQ Safety Program for Ambulatory Surgery Management Practices for Sustainability Module 2: Daily Huddles Sample “Plan-Do-Study-Act”[footnoteRef:1] Form [1: “Plan-Do-Study-Act” refers to a method for testing changes in clinical practice. In the “plan” step, you lay out the specifications of you…

986. Sample “Plan-Do-Study-Act” Form | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/management/pdsa-form.html
     June 01, 2017 - Sample “Plan-Do-Study-Act” Form Use this form to help you plan your introduction of visual management.  It includes sections to help you plan and manage all the tasks necessary to introduce a visual management board.  You can also use it to gauge the success of your initial attempt at introducing vi…

987. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35181/psn-pdf
     June 23, 2009 - Communication during trauma resuscitation: do we know what is happening? June 23, 2009 Bergs EAG, Rutten FLPA, Tadros T, et al. Communication during trauma resuscitation: do we know what is happening? Injury. 2005;36(8):905-11. https://psnet.ahrq.gov/issue/communication-during-trauma-resuscitation-do-we-know-what-…

988. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39489/psn-pdf
     June 11, 2010 - What happens between visits? Adverse and potential adverse events among a low-income, urban, ambulatory population with diabetes. June 11, 2010 Sarkar U, Handley MA, Gupta R, et al. What happens between visits? Adverse and potential adverse events among a low-income, urban, ambulatory population with diabetes. Qua…

989. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44359/psn-pdf
     January 06, 2016 - What happens when healthcare innovations collide? January 6, 2016 Pendharkar SR, Woiceshyn J, da Silveira GJC, et al. What happens when healthcare innovations collide? BMJ Qual Saf. 2016;25(1):9-13. doi:10.1136/bmjqs-2015-004441. https://psnet.ahrq.gov/issue/what-happens-when-healthcare-innovations-collide Innovat…

990. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44132/psn-pdf
     May 13, 2015 - Adverse outcomes: why bad things happen to good people. May 13, 2015 Sonnenberg A. Adverse outcomes: why bad things happen to good people. Clin Gastroenterol Hepatol. 2015;13(5):820-3.e1. doi:10.1016/j.cgh.2014.07.064. https://psnet.ahrq.gov/issue/adverse-outcomes-why-bad-things-happen-good-people This commentary…

991. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50677/psn-pdf
     November 20, 2019 - What Happens When Doctors Make Diagnostic Errors? November 20, 2019 The Peoples Pharmacy. Show 1186: National Public Radio. October 24, 2019. https://psnet.ahrq.gov/issue/what-happens-when-doctors-make-diagnostic-errors Misdiagnosis growing area of concern in health care. This radio feature explores three commonly …

992. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47757/psn-pdf
     February 06, 2019 - Doctors make mistakes. A new documentary explores what happens when they do—and how to fix it. February 6, 2019 Park A. Time Magazine. January 24, 2019. https://psnet.ahrq.gov/issue/doctors-make-mistakes-new-documentary-explores-what-happens-when-they- do-and-how-fix-it This news article reports on the documentar…

993. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46506/psn-pdf
     October 11, 2017 - Getting Ahead of Harm Before It Happens: A Guide About Proactive Analysis for Improving Surgical Care Safety. October 11, 2017 Wiley K, Davies JM. Edmonton, AB: Canadian Patient Safety Institute; 2017. https://psnet.ahrq.gov/issue/getting-ahead-harm-it-happens-guide-about-proactive-analysis-improving- surgical-car…

994. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50719/psn-pdf
     December 04, 2019 - A lot happens when you report a hazard or error to ISMP—there’s no “black hole” here! December 4, 2019 ISMP Medication Safety Alert! Acute Care Edition. November 7, 2019 https://psnet.ahrq.gov/issue/lot-happens-when-you-report-hazard-or-error-ismp-theres-no-black-hole-here The reporting and analysis of incidents i…

995. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39080/psn-pdf
     November 04, 2009 - How could this happen? November 4, 2009 Westfall SS; Mascia K. People. October 5, 2009. https://psnet.ahrq.gov/issue/how-could-happen This story discusses an instance of mistakenly implanted embryos and the impact of the error on the two families involved. https://psnet.ahrq.gov/issue/how-could-happen

996. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47914/psn-pdf
     May 22, 2019 - Hospitals look to computers to predict patient emergencies before they happen. May 22, 2019 Ross C. STAT. May 13, 2019. https://psnet.ahrq.gov/issue/hospitals-look-computers-predict-patient-emergencies-they-happen Nuisance alarms, interruptions, and insufficient staff availability can hinder effective monitoring …

997. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40815/psn-pdf
     September 28, 2011 - Program encourages reporting accidents waiting to happen: the Good Catch Awards. September 28, 2011 Minnesota Hospital Association. https://psnet.ahrq.gov/issue/program-encourages-reporting-accidents-waiting-happen-good-catch-awards This news article highlights a program at Johns Hopkins Medicine that engages clin…

998. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73222/psn-pdf
     May 05, 2021 - Fatal mistakes: why do ten-fold medication errors in children keep happening? May 5, 2021 Parry C. The Pharmaceutical Journal.  April 22 2021. https://psnet.ahrq.gov/issue/fatal-mistakes-why-do-ten-fold-medication-errors-children-keep-happening Weight-based prescribing in children harbors challenges to accura…

999. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47678/psn-pdf
     December 19, 2018 - When mistakes happen. December 19, 2018 Beck DL. ASH Clinical News. December 1, 2018. https://psnet.ahrq.gov/issue/when-mistakes-happen This article provides an overview of efforts to understand and improve patient safety and covers topics such as the epidemiology of error, its impact on the individuals involved, …

1000. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44327/psn-pdf
      August 26, 2015 - Safely Home: What Happens When People Leave Hospital Care Settings? August 26, 2015 London, UK: Healthwatch England; July 2015. https://psnet.ahrq.gov/issue/safely-home-what-happens-when-people-leave-hospital-care-settings Discharges are vulnerable periods for patients, often due to miscommunication, delays, and l…