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Showing results for "occur".

21. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/46827/psn-pdf
    March 14, 2018 - Prior research has shown that medication errors occur frequently and are associated with a longer hospital … The authors estimate that 237 million medication errors occur annually and that 66 million of these … The majority of potentially harmful errors likely occur in the outpatient setting where most medications

22. How to Talk About Patient Safety. | PSNet
    psnet.ahrq.gov/issue/how-talk-about-patient-safety
    June 24, 2019 - They encourage continued use of the aviation metaphor to illustrate why medical errors occur and how … when done correctly, can help health care systems identify safety hazards, regain trust after they occur

23. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/836808/psn-pdf
    March 30, 2022 - medication-safety-emergency-department-study-serious-medication-errors- reported-101-hospitals Medication errors can occur … Errors were more likely to occur on weekends and between 12:00 pm and midnight; patients were more likely

24. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/72820/psn-pdf
    March 10, 2021 - persist with long-term use of CPOE systems, but future research should explore the types of errors that occur … , when they occur, and the system factors contributing to the errors.

25. Critical incidents involving the medical emergency team: a 5-year retrospective assessment for healthcare improvement. | PSNet
    psnet.ahrq.gov/issue/critical-incidents-involving-medical-emergency-team-5-year-retrospective-assessment
    November 11, 2020 - effectiveness of medical emergency teams (MET) has been widely researched , critical incidents that occur … Related Resources From the Same Author(s) Do falls and other safety issues occur

26. The potential for improved teamwork to reduce medical errors in the emergency department. | PSNet
    psnet.ahrq.gov/issue/potential-improved-teamwork-reduce-medical-errors-emergency-department
    July 07, 2021 - to introduce emergency department communities to teamwork systems, teamwork failures that commonly occur … includes retrospective analysis of more than 50 incidents suggesting that nearly nine teamwork failures occur

27. Medication safety in the emergency department: a study of serious medication errors reported by 101 hospitals from 2011 to 2020. | PSNet
    psnet.ahrq.gov/issue/medication-safety-emergency-department-study-serious-medication-errors-reported-101-hospitals
    March 24, 2021 - Medication errors can occur in all clinical settings , but can have especially devastating results … Errors were more likely to occur on weekends and between 12:00 pm and midnight; patients were more likely

28. Incidence and method of suicide in hospitals in the United States. | PSNet
    psnet.ahrq.gov/issue/incidence-and-method-suicide-hospitals-united-states
    October 04, 2023 - Little is known about the epidemiology of hospital suicides other than that they are rare and occur mostly … Nationally, between 49 and 65 hospital suicides occur each year.

29. Failure Mode and Effect Analysis (FMEA) | PSNet
    psnet.ahrq.gov/glossary/failure-mode-and-effect-analysis-fmea
    September 13, 2021 - FMEA begins with a complete process mapping that identifies all the steps that must occur for a given … process to occur (e.g., programming an infusion pump or preparing an intravenous medication in the pharmacy

30. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/33576/psn-pdf
    December 15, 2024 - wrong-procedure, wrong-patient errors" (WSPEs) are rightly termed never events—errors that should never occur … A seminal study estimated that such errors occur in approximately 1 of 112,000 surgical procedures, … It is worth noting, however, that many cases of WSPEs would still occur despite full adherence to the

31. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/35588/psn-pdf
    February 03, 2011 - This theory asks the question of what should change, to what should it change, and how should change occur … Responses are framed with discussion of six thought processes that must occur at an organization for

32. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/34784/psn-pdf
    June 24, 2015 - to introduce emergency department communities to teamwork systems, teamwork failures that commonly occur … includes retrospective analysis of more than 50 incidents suggesting that nearly nine teamwork failures occur

33. Anatomy and pathophysiology of errors occurring in clinical radiology practice. | PSNet
    psnet.ahrq.gov/issue/anatomy-and-pathophysiology-errors-occurring-clinical-radiology-practice
    February 01, 2011 - Commentary Anatomy and pathophysiology of errors occurring in clinical radiology practice. Citation Text: Brook OR, O'Connell AM, Thornton E, et al. Quality initiatives: anatomy and pathophysiology of errors occurring in clinical radiology practice. Radiographics. 2010;30(5):1401-10. d…

34. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/33579/psn-pdf
    September 15, 2024 - The systems approach holds that efforts to catch human errors before they occur or block them from causing … Active errors almost always involve frontline personnel and occur at the point of contact between a … In this construct, slips represent failures of schematic behaviors, or lapses in concentration, and occur … FMEA begins with identifying all the steps that must occur for a given process to occur.

35. Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: are they preventable? | PSNet
    psnet.ahrq.gov/issue/wrong-sidewrong-site-wrong-procedure-and-wrong-patient-adverse-events-are-they-preventable
    February 24, 2011 - A prior study indicated a rate of approximately 1 case per 112,000 surgeries, but WSPEs may occur in … from both mandatory and voluntary reporting systems indicates that approximately 1300 to 2700 WSPEs occur

36. Medication errors related to computerized provider order entry systems in hospitals and how they change over time: a narrative review. | PSNet
    psnet.ahrq.gov/issue/medication-errors-related-computerized-provider-order-entry-systems-hospitals-and-how-they
    April 07, 2021 - persist with long-term use of CPOE systems, but future research should explore the types of errors that occur … , when they occur, and the system factors contributing to the errors.

37. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/44767/psn-pdf
    January 20, 2016 - failures-modern Despite widespread efforts to improve health care safety, medical errors continue to occur … psychology, including theories related to behavior and cognition, to understand why care failures occur

38. Never Events | PSNet
    psnet.ahrq.gov/primer/never-events
    June 15, 2024 - , in reference to particularly shocking medical errors—such as wrong-site surgery—that should never occur … However, when Never Events occur, they are devastating to patients and may indicate a fundamental safety … A 2013  study  estimated that more than 4000 surgical never events occur yearly in the United States.

39. "What's psychology got to do with it?" Applying psychological theory to understanding failures in modern healthcare settings. | PSNet
    psnet.ahrq.gov/issue/whats-psychology-got-do-it-applying-psychological-theory-understanding-failures-modern
    July 10, 2017 - Despite widespread efforts to improve health care safety, medical errors continue to occur. … psychology , including theories related to behavior and cognition , to understand why care failures occur

40. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/36315/psn-pdf
    July 10, 2008 - A prior study indicated a rate of approximately 1 case per 112,000 surgeries, but WSPEs may occur in … from both mandatory and voluntary reporting systems indicates that approximately 1300 to 2700 WSPEs occur