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Total Results: 4,038 records

Showing results for "occur".

101. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50786/psn-pdf
     January 08, 2020 - a complex environment that serves a vulnerable population at increased risk for harm should errors occur

102. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/853061/psn-pdf
     August 30, 2023 - Part One of this review summarizes existing definitions for drug shortages and the harms that can occur

103. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/48082/psn-pdf
     June 19, 2019 - patients age 65 and older on chronic medications found that unintentional medication discontinuation does occur

104. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/853977/psn-pdf
     September 27, 2023 - the British National Health System (NHS) and the factors that allowed continued criminal activity to occur

105. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74076/psn-pdf
     November 17, 2021 - https://psnet.ahrq.gov/issue/influence-perioperative-handoffs-complications-and-outcomes Handoffs occur

106. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/854897/psn-pdf
     October 31, 2023 - These errors can occur at any stage in the medication use process, from prescribing to administration … To understand how such medication errors can occur, it is helpful to review James Reason’s Swiss Cheese … According to Reason, accidents within most complex systems (e.g., healthcare) occur from the breakdown … False alerts occur without any actual event, whereas nonactionable alerts result from events that lack … initial data entry to final medication administration, had vulnerabilities that allowed the error to occur

107. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/853773/psn-pdf
     September 27, 2023 - Wrong site or wrong patient errors, as in the case above, reportedly occur in approximately 1 in every … Despite system changes to prevent medical errors and “never events,” they will likely continue to occur … When “never events” occur, as in this case, it is important to disclose the error clearly, support the … It is expected that hospital staff perform a root cause analysis when such events occur, clearly disclose … When “never events” or sentinel events occur, the impact on the health care providers should be taken

108. Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose | PSNet
     psnet.ahrq.gov/web-mm/weight-and-height-juxtaposition-electronic-medical-record-causing-accidental-medication
     March 15, 2023 - These errors can occur at any stage in the medication use process , from prescribing to administration … To understand how such medication errors can occur, it is helpful to review James Reason’s Swiss Cheese … According to Reason, accidents within most complex systems (e.g., healthcare) occur from the breakdown … False alerts occur without any actual event, whereas nonactionable alerts result from events that lack … initial data entry to final medication administration, had vulnerabilities that allowed the error to occur

109. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867633/psn-pdf
     February 26, 2025 - preventable and that healthcare systems should be able to rapidly identify and treat complications when they occur

110. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/837744/psn-pdf
     July 27, 2022 - //psnet.ahrq.gov/issue/medication-orders-future-start-dates-how-far-away-too-far Human errors that occur

111. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/838928/psn-pdf
     October 26, 2022 - they-cant-ignore-us-any-more-five-women-long-covid-and-medical-misogyny Disrespect for women around the world is known to occur

112. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73615/psn-pdf
     August 18, 2021 - The story is coupled with a broader discussion on the extent of diagnostic errors and reasons they occur

113. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74216/psn-pdf
     December 22, 2021 - strategy to reduce the impact of implicit ethnic bias, while arguing that fundamental change will occur

114. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/837042/psn-pdf
     April 04, 2022 - covered support respectful communication with patients, families and clinicians after medical errors occur

115. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/851452/psn-pdf
     July 19, 2023 - Despite extensive research and interventions, medication prescribing errors in hospital continue to occur

116. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/837517/psn-pdf
     June 22, 2022 - Secretary Jeremy Hunt intended to help the institution reach a place where zero patient harm will occur

117. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/61070/psn-pdf
     October 28, 2020 - patient-outcomes Retained surgical items (RSIs) are considered ‘never events’ but they continue to occur

118. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74194/psn-pdf
     December 15, 2021 - ; https://psnet.ahrq.gov/issue/age-related-covid-19-vaccine-mix-ups Vaccine missteps are known to occur

119. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49393/psn-pdf
     April 01, 2003 - consisted of failure to identify the appropriate limb of colon to bring up for colostomy, which can occur … This error is not confined to laparoscopy; it can occur during open surgery, especially when multiple … psnet.ahrq.gov//#references Any time error prevention relies solely on vigilance, errors will eventually occur—due … It is important to note that mechanical obstruction can occur for reasons other than the error described

120. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/838029/psn-pdf
     September 07, 2022 - emergency-preparedness-be-ready-unanticipated-electronic-health-record-ehr- downtime Unanticipated health information system downtime can occur