Results

Total Results: 1,064 records

Showing results for "occur".

321. Cybersecurity and How to Maintain Patient Safety | PSNet
     psnet.ahrq.gov/perspective/cybersecurity-and-how-maintain-patient-safety
     March 27, 2024 - important to figure out what these issues are and how you are going to work through them when they occur … Often when these events occur, staff are told to not talk about them, but at some point, you need to

322. In Conversation With... Elsabeth Kalenderian, DDS, MPH, PhD and Muhammad F. Walji, PhD | PSNet
     psnet.ahrq.gov/perspective/conversation-elsabeth-kalenderian-dds-mph-phd-and-muhammad-f-walji-phd
     December 22, 2020 - adverse events and interpreting that data takes a lot more effort than measuring whether care processes occur … AEs they thought were more and less common in dental care, and in particular which AEs should never occur

323. Navigating Complications: The Unintended Journey of a Guidewire During Dialysis Catheter Placement | PSNet
     psnet.ahrq.gov/web-mm/navigating-complications-unintended-journey-guidewire-during-dialysis-catheter-placement
     February 23, 2022 - By Sharmilee Vuyyuru, DO, and Nandakishor Kapa, MD This case demonstrates how an adverse event can occur … identify and retrain operators when new equipment is introduced, and to debrief after complications occur

324. Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations | PSNet
     psnet.ahrq.gov/web-mm/errors-managing-open-wound-elbow-leading-multiple-complications-and-operations
     September 27, 2023 - Complications (e.g., cellulitis, abscess, osteomyelitis, fistula, mechanical impairment, etc.) may occur … itself must be considered because damage to important structures (e.g., arteries, nerves, tendons) may occur … It is usually better to assume an infection will occur than to hope it won’t.

325. Root cause analysis of adverse events involving opioid overdoses in the Veterans Health Administration. | PSNet
     psnet.ahrq.gov/issue/root-cause-analysis-adverse-events-involving-opioid-overdoses-veterans-health-administration
     November 17, 2021 - Study Root cause analysis of adverse events involving opioid overdoses in the Veterans Health Administration. Citation Text: Norris B, Soncrant C, Mills PD, et al. Root cause analysis of adverse events involving opioid overdoses in the Veterans Health Administration. Jt Comm J Qual Patie…

326. Root cause analysis of ICU adverse events in the Veterans Health Administration. | PSNet
     psnet.ahrq.gov/issue/root-cause-analysis-icu-adverse-events-veterans-health-administration
     June 23, 2021 - Study Root cause analysis of ICU adverse events in the Veterans Health Administration. Citation Text: Corwin GS, Mills PD, Shanawani H, et al. Root Cause Analysis of ICU Adverse Events in the Veterans Health Administration. Jt Comm J Qual Patient Saf. 2017;43(11):580-590. doi:10.1016/j.j…

327. Veterans Health Administration response to the COVID-19 crisis: surveillance to action. | PSNet
     psnet.ahrq.gov/issue/veterans-health-administration-response-covid-19-crisis-surveillance-action
     November 17, 2021 - Commentary Veterans Health Administration response to the COVID-19 crisis: surveillance to action. Citation Text: Charles MA, Yackel EE, Mills PD, et al. Veterans Health Administration response to the COVID-19 crisis: surveillance to action. J Patient Saf. 2022;18(7):686-691. doi:10.1097…

328. Diagnostic Failure: The Growing Deficit | PSNet
     psnet.ahrq.gov/web-mm/diagnostic-failure-growing-deficit
     June 01, 2005 - Provide contingency plans focused on the next step and a plan to reengage if the expected outcome did not occur

329. Root Cause Analysis | PSNet
     psnet.ahrq.gov/primer/root-cause-analysis
     March 30, 2022 - Root Cause Analysis Citation Text: Root Cause Analysis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

330. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33572/psn-pdf
     December 15, 2024 - associated with each behavior are also different: failures of schematic behavior are called slips and occur

331. Interdisciplinary teamwork | PSNet
     psnet.ahrq.gov/curated-library/interdisciplinary-teamwork
     April 17, 2025 - team members collectively reflect on actions and behaviors, and the context in which these actions occur … catalyzed 7 years of efforts to bring patient safety to the forefront and explain what future steps must occur

332. Paroxysmal Supraventricular Tachycardia Masquerading as Panic Attacks | PSNet
     psnet.ahrq.gov/web-mm/paroxysmal-supraventricular-tachycardia-masquerading-panic-attacks
     September 01, 2017 - The symptom may be very brief such as may occur with premature beats or sustained, with or without a … correlation of patients’ symptoms with cardiac rhythms because arrhythmia episodes may be too infrequent to occur

333. Update: Patient Engagement in Safety | PSNet
     psnet.ahrq.gov/perspective/update-patient-engagement-safety
     January 01, 2017 - engaged patients to help health care systems identify safety hazards, regain trust after safety hazards occur

334. A review of adverse event reports from emergency departments in the Veterans Health Administration. | PSNet
     psnet.ahrq.gov/issue/review-adverse-event-reports-emergency-departments-veterans-health-administration
     November 17, 2021 - Study A review of adverse event reports from emergency departments in the Veterans Health Administration. Citation Text: Gill S, Mills PD, Watts BV, et al. A Review of Adverse Event Reports From Emergency Departments in the Veterans Health Administration. J Patient Saf. 2021;17(8):e898-…

335. Adverse patient safety events during the COVID epidemic. | PSNet
     psnet.ahrq.gov/issue/adverse-patient-safety-events-during-covid-epidemic
     May 03, 2023 - Study Adverse patient safety events during the COVID epidemic. Citation Text: Yackel EE, Knowles RS, Jones CM, et al. Adverse patient safety events during the COVID epidemic. J Patient Saf. 2023;19(5):340-345. doi:10.1097/pts.0000000000001129. Copy Citation Format: DOI Goog…

336. Delays in diagnosis, treatment, and surgery: root causes, actions taken, and recommendations for healthcare improvement. | PSNet
     psnet.ahrq.gov/issue/delays-diagnosis-treatment-and-surgery-root-causes-actions-taken-and-recommendations
     March 25, 2020 - Study Delays in diagnosis, treatment, and surgery: root causes, actions taken, and recommendations for healthcare improvement. Citation Text: Politi RE, Mills PD, Zubkoff L, et al. Delays in diagnosis, treatment, and surgery: root causes, actions taken, and recommendations for healthcare…

337. Hemodialysis bleeding events and deaths: an 18-year retrospective analysis of patient safety and root cause analysis reports in the Veterans Health Administration. | PSNet
     psnet.ahrq.gov/issue/hemodialysis-bleeding-events-and-deaths-18-year-retrospective-analysis-patient-safety-and
     June 23, 2021 - Study Hemodialysis bleeding events and deaths: an 18-year retrospective analysis of patient safety and root cause analysis reports in the Veterans Health Administration. Citation Text: Walton E, Charles M, Morrish W, et al. Hemodialysis bleeding events and deaths: an 18-year retrospectiv…

338. Signout Fallout | PSNet
     psnet.ahrq.gov/web-mm/signout-fallout
     November 16, 2022 - Handoffs occur in the hospital every time providers change shift and whenever a patient changes locations

339. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33594/psn-pdf
     November 18, 2021 - A ‘cold debrief’ may occur later in the day or week and is often held in a different space than the … Events Clinical event debriefing can be challenging to implement due to uncertainty about when it will occur

340. Teaching medical error disclosure to physicians-in-training: a scoping review. | PSNet
     psnet.ahrq.gov/issue/teaching-medical-error-disclosure-physicians-training-scoping-review
     June 09, 2015 - Review Teaching medical error disclosure to physicians-in-training: a scoping review. Citation Text: Stroud L, Wong BM, Hollenberg E, et al. Teaching medical error disclosure to physicians-in-training: a scoping review. Acad Med. 2013;88(6):884-92. doi:10.1097/ACM.0b013e31828f898f. Cop…