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Total Results: 4,231 records

Showing results for "occur".

241. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74086/psn-pdf
     November 17, 2021 - Review of reported adverse events occurring among the homeless veteran population in the Veterans Health Administration. November 17, 2021 Soncrant C, Mills PD, Pendley Louis RP, et al. Review of reported adverse events occurring among the homeless veteran population in the Veterans Health Administration. J Patien…

242. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60159/psn-pdf
     March 25, 2020 - Root cause analyses of reported adverse events occurring during gastrointestinal scope and tube placement procedures in the Veterans Health Association. March 25, 2020 Soncrant C, Mills PD, Neily J, et al. Root cause analyses of reported adverse events occurring during gastrointestinal scope and tube placement pro…

243. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47711/psn-pdf
     June 14, 2019 - Type 1 diabetes defined by severe insulin deficiency occurs after 30 years of age and is commonly treated as type 2 diabetes. June 14, 2019 Thomas NJ, Lynam AL, Hill A, et al. Type 1 diabetes defined by severe insulin deficiency occurs after 30 years of age and is commonly treated as type 2 diabetes. Diabetologia.…

244. 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

245. 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

246. 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

247. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866580/psn-pdf
     August 28, 2024 - organizational guidelines, federal reports, and equipment redesign, tubing misconnections continue to occur

248. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866517/psn-pdf
     August 14, 2024 - This article raises the issue of data-driven feedback loop failures which occur when disease incidence

249. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/865522/psn-pdf
     April 10, 2024 - identifying-electronic-medication-administration-record-emar-usability-issues-patient-safety https://psnet.ahrq.gov/issue/review-medication-errors-are-new-or-likely-occur-more-frequently-electronic-medication

250. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866583/psn-pdf
     August 28, 2024 - assessing-stops-framework-coping-intraoperative-errors-evidence-efficacy- hints-hubris-and When intraoperative errors occur

251. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73109/psn-pdf
     April 07, 2021 - common-general-surgical-never-events-analysis-nhs-england-never-event- data Never events, a significant type of adverse event, should never occur

252. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44873/psn-pdf
     March 21, 2016 - communication breakdowns led to patient harm, this report explores selected specialties where such failures occur

253. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43238/psn-pdf
     June 04, 2014 - issue/administering-just-diluent-or-one-two-vaccine-components-leaves-patients- unprotected Errors occur

254. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45093/psn-pdf
     September 04, 2016 - Discussing how patient harm can still occur even with these elements in place, this article highlights

255. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37649/psn-pdf
     September 27, 2017 - anesthesia-machine-cause-intraoperative-code-red-labor-and-delivery-suite https://psnet.ahrq.gov/issue/clinicians-guide-surgical-fires-how-they-occur-how-prevent-them-how-put-them-out

256. 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

257. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49514/psn-pdf
     July 01, 2006 - worrisome adverse effects (hypotension, renal insufficiency, angioedema, and hyperkalemia) tend to occur … Points The addition of a new medication requires monitoring for adverse drug events, which typically occur …   Digoxin (acute overdose) Hyperkalemia following acute overdose predicts poor outcome Heparin Can occur …   Potassium supplements   Potassium-sparing diuretics (amiloride, triamterene) Hyperkalemia can occur

258. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34973/psn-pdf
     September 29, 2017 - respect for patient autonomy plays in developing disclosure policies, and the culture change that must occur

259. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47309/psn-pdf
     August 22, 2018 - for patient safety as it applies to inpatient psychiatry, define the types of adverse events that occur

260. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45431/psn-pdf
     November 22, 2017 - interpretation errors associated with chest radiographs of children to illustrate common mistakes that can occur