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Total Results: 3,543 records

Showing results for "consequences".

281. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44761/psn-pdf
     January 06, 2016 - two-fatal-cases-accidental-intrathecal-vincristine-administration-learning-death- events Incorrectly administered vincristine can lead to serious adverse consequences … psnet.ahrq.gov/issue/preventing-vincristine-administration-errors https://psnet.ahrq.gov/issue/fatal-consequences-simple-mistake-how-can-patient-be-saved-inadvertent-intrathecal

282. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47382/psn-pdf
     August 29, 2018 - parenteral-opioid-shortage-treating-pain-during-opioid-overdose-epidemic Well-intentioned system-level efforts to improve care can result in unintended consequences … parenteral-opioid-shortage-treating-pain-during-opioid-overdose-epidemic https://psnet.ahrq.gov/issue/systematic-review-unintended-consequences-clinical-interventions-reduce-adverse-outcomes

283. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38799/psn-pdf
     September 29, 2009 - provider order entry (CPOE) systems continue to be slowly adopted while concerns about their unintended consequences … psnet.ahrq.gov/issue/use-electronic-health-records-us-hospitals https://psnet.ahrq.gov/issue/types-unintended-consequences-related-computerized-provider-order-entry

284. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45833/psn-pdf
     January 30, 2018 - impact-electronic-medical-records-hospital-acquired-adverse-safety-events- differential Electronic health records enhance patient safety, but they also have unintended consequences … benefits-health-information-technology-review-recent-literature-shows-predominantly-positive https://psnet.ahrq.gov/issue/some-unintended-consequences-information-technology-health-care-nature-patient-care

285. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47016/psn-pdf
     June 25, 2018 - efforts to proactively identify and address safety concerns may fall short and lead to unintended consequences … digital-health-and-patient-safety https://psnet.ahrq.gov/issue/why-things-bite-back-technology-and-revenge-unintended-consequences

286. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36017/psn-pdf
     June 14, 2006 - The authors describe the assumptions and consequences of control-based management and compare it to … Building on this background, they discuss the human resource practices and behavioral consequences of

287. Alert Fatigue | PSNet
     psnet.ahrq.gov/primer/alert-fatigue
     March 15, 2025 - finding is intuitive, but also raises the important implication that without system redesign, the safety consequences … Current context Alert fatigue (and the unintended consequences of the computerization of health care) … In order to mitigate these consequences—including alert fatigue—The Joint Commission recommended improving … One limitation to addressing alert fatigue pertains to the legal consequences of removing alerts. … September 1, 2016 A clinical case of electronic health record drug alert fatigue: consequences

288. Implementing medication reconciliation in outpatient pediatrics. | PSNet
     psnet.ahrq.gov/issue/implementing-medication-reconciliation-outpatient-pediatrics
     September 23, 2020 - changing outpatient clinician workflow and the steps this organization took to minimize unintended consequences … July 3, 2013 Small patients, big consequences in medical errors.

289. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/836839/psn-pdf
     March 31, 2022 - defined as an individual’s “sense of being able to show and employ oneself without fear of negative consequences … Potential Negative Consequences in Psychologically Safe Environments It is generally accepted that a … Therefore, it is somewhat counterintuitive to think that negative consequences could be associated with … If there are negative consequences of high psychological safety, then a better understanding is required … to maximize the positive influences and minimize the negative consequences.

290. Implementing computerized provider order entry in acute care hospitals in the United States could generate substantial savings to society. | PSNet
     psnet.ahrq.gov/issue/implementing-computerized-provider-order-entry-acute-care-hospitals-united-states-could
     March 30, 2022 - decision support is considered to be integral to patient safety, high implementation costs and unintended consequences … September 1, 2016 Evaluation of medium-term consequences of implementing commercial computerized

291. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/845651/psn-pdf
     November 17, 2016 - mri-centers-performing-lumbar-spine-mri- examinations Diagnostic errors and the resulting delays in care can have serious consequences … psnet.ahrq.gov/issue/undiagnosed-breast-cancer-mr-imaging-analysis-causes https://psnet.ahrq.gov/web-mm/consequences-miscommunication-regarding-possible-artifact

292. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37346/psn-pdf
     March 28, 2012 - While unintended consequences can result from adoption of CPOE systems, point-of- care solutions have … medication-dispensing-errors-and-potential-adverse-drug-events-and-after-implementing-bar https://psnet.ahrq.gov/issue/types-unintended-consequences-related-computerized-provider-order-entry

293. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41154/psn-pdf
     November 26, 2014 - misses increased significantly after CPOE implementation, highlighting the potential for unintended consequences … effects-two-commercial-electronic-prescribing-systems-prescribing-error-rates-hospital https://psnet.ahrq.gov/issue/types-unintended-consequences-related-computerized-provider-order-entry

294. Improving transfusion safety in the operating room with a barcode scanning system designed specifically for the surgical environment and existing electronic medical record systems: an interrupted time series analysis. | PSNet
     psnet.ahrq.gov/issue/improving-transfusion-safety-operating-room-barcode-scanning-system-designed-specifically
     February 01, 2023 - Transfusion errors due to patient  misidentification  can have  serious consequences .  … August 10, 2022 Intended and unintended consequences: changes in opioid prescribing practices

295. Two fatal cases of accidental intrathecal vincristine administration: learning from death events. | PSNet
     psnet.ahrq.gov/issue/two-fatal-cases-accidental-intrathecal-vincristine-administration-learning-death-events
     March 24, 2021 - Incorrectly administered vincristine can lead to serious adverse consequences . … August 26, 2020 Intended and unintended consequences: changes in opioid prescribing practices

296. The role of technology in clinician-to-clinician communication. | PSNet
     psnet.ahrq.gov/issue/role-technology-clinician-clinician-communication
     September 09, 2015 - This commentary discusses electronic communication in hospitals, including unintended consequences … Related Resources It's like sending a message in a bottle: a qualitative study of the consequences

297. The disruptive orthopaedic surgeon: implications for patient safety and malpractice liability.  | PSNet
     psnet.ahrq.gov/issue/disruptive-orthopaedic-surgeon-implications-patient-safety-and-malpractice-liability
     August 20, 2018 - This commentary discusses disruptive behavior in orthopedic surgery, including causes, consequences … July 20, 2022 WebM&M Cases The Consequences of Miscommunication

298. Responding to large-scale testing errors. | PSNet
     psnet.ahrq.gov/issue/responding-large-scale-testing-errors
     December 18, 2008 - Using two case examples, this article analyzes the causes and consequences of laboratory testing errors … November 11, 2009 Causes, consequences, detection, and prevention of identification errors

299. The tension between promoting mobility and preventing falls in the hospital. | PSNet
     psnet.ahrq.gov/issue/tension-between-promoting-mobility-and-preventing-falls-hospital
     April 24, 2018 - This commentary discusses unintended consequences of the well-intentioned strategy of keeping older … April 24, 2018 Medicare nonpayment, hospital falls, and unintended consequences.

300. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38412/psn-pdf
     September 01, 2016 - This phenomenon has been previously documented as one of several types of unintended consequences of … https://psnet.ahrq.gov//#clinicaldecisionsupportsystem https://psnet.ahrq.gov/issue/types-unintended-consequences-related-computerized-provider-order-entry