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Total Results: 1,064 records

Showing results for "occur".

341. Choosing your words carefully: how physicians would disclose harmful medical errors to patients. | PSNet
     psnet.ahrq.gov/issue/choosing-your-words-carefully-how-physicians-would-disclose-harmful-medical-errors-patients
     February 16, 2011 - Study Classic Choosing your words carefully: how physicians would disclose harmful medical errors to patients. Citation Text: Gallagher TH, Garbutt J, Waterman AD, et al. Choosing your words carefully: how physicians would disclose harmful medical errors to pa…

342. Procedural Mishap: Learning Curve? | PSNet
     psnet.ahrq.gov/web-mm/procedural-mishap-learning-curve
     April 28, 2021 - Procedural Mishap: Learning Curve? Citation Text: Gibbs VC, Leape L. Procedural Mishap: Learning Curve?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML En…

343. Debriefing for Clinical Learning | PSNet
     psnet.ahrq.gov/primer/debriefing-clinical-learning
     September 15, 2024 - 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

344. Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected | PSNet
     psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect-unexpected
     September 25, 2024 - Considerations Even with implementation of all available preventive measures, serious adverse events still occur

345. Identifying Safety Events in the Prehospital Setting | PSNet
     psnet.ahrq.gov/perspective/identifying-safety-events-prehospital-setting
     May 16, 2022 - Identifying Safety Events in the Prehospital Setting May 16, 2022  Also Read the Conversation View more articles from the same authors. Citation Text: Crowe RP, Mossburg SE, Dowell P. Identifying Safety Events in the Prehospital Setting. PSNet [internet]. Rockvi…

346. In Conversation With... Remle P. Crowe, PhD | PSNet
     psnet.ahrq.gov/perspective/conversation-remle-p-crowe-phd
     May 16, 2022 - In Conversation With... Remle P. Crowe, PhD May 16, 2022  Also Read the Essay Citation Text: In Conversation With.. Remle P. Crowe, PhD . PSNet [internet]. 2022.In Conversation With... Remle P. Crowe, PhD . PSNet [internet]. Rockville (MD): Agency for Healthcare …

347. Two Wrongs Don't Make a Right (Kidney) | PSNet
     psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney
     April 01, 2010 - SPOTLIGHT CASE Two Wrongs Don't Make a Right (Kidney) Citation Text: DeVine JG. Two Wrongs Don't Make a Right (Kidney). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Schola…

348. Application of Safety-II Principles | PSNet
     psnet.ahrq.gov/perspective/application-safety-ii-principles
     August 28, 2024 - There are many dependencies for things to go well, and there are varying conditions that occur throughout … conversation in this way has created greater engagement of our team members and enhances the learning that can occur

349. Routine Goes Awry | PSNet
     psnet.ahrq.gov/web-mm/routine-goes-awry
     September 23, 2020 - Airway obstruction is a much less common complication but is more likely to occur in certain populations

350. How useful are voluntary medication error reports? The case of warfarin-related medication errors. | PSNet
     psnet.ahrq.gov/issue/how-useful-are-voluntary-medication-error-reports-case-warfarin-related-medication-errors
     May 27, 2011 - Study How useful are voluntary medication error reports? The case of warfarin-related medication errors. Citation Text: Zhan C, Smith SR, Keyes MA, et al. How useful are voluntary medication error reports? The case of warfarin-related medication errors. Jt Comm J Qual Patient Saf. 2008;3…

351. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy. | PSNet
     psnet.ahrq.gov/web-mm/false-assumptions-result-missed-pneumothorax-after-bronchoscopy-transbronchial-biopsy
     March 15, 2023 - SPOTLIGHT CASE False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy. Citation Text: Kuhn BT, Chau-Etchepare F. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy.. PSNet [internet]. Rockville (MD): Agency for …

352. Code Blue—Where To? | PSNet
     psnet.ahrq.gov/web-mm/code-blue-where
     March 30, 2020 - Some of these errors can (and do) occur in cardiac arrests on medical wards and other inpatient care … Public (Non–Patient-Care) Areas of the Hospital About 1% of all in-hospital cardiac arrests will occur

353. Prolonged DKA in Pregnancy: A Case of Communication Breakdown. | PSNet
     psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown
     June 28, 2023 - up to 5% of all diabetic pregnancies. 1,2 While more common with type 1 DM, euglycemic DKA can also occur … In pregnancy, it can occur in patients with either pregestational or gestational diabetes.

354. Spotlight (pdf file)
     psnet.ahrq.gov/sites/default/files/2022-01/final_spotlight_stacked_opioid_administration_01.03.2022.pdf
     January 01, 2022 - known as “dose stacking.” 19 Opioid Pharmacokinetics and “Dose Stacking” (2) • Dose stacking can occur … • Dose stacking can also occur when a patient receives opioids via numerous sources or routes.

355. Strategies and Approaches for Investigating Patient Safety Events | PSNet
     psnet.ahrq.gov/primer/strategies-and-approaches-investigating-patient-safety-events
     March 15, 2025 - Strategies and Approaches for Investigating Patient Safety Events Citation Text: Shaikh U. Strategies and Approaches for Investigating Patient Safety Events. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Fo…

356. A high-reliability organization framework for health care: a multiyear implementation strategy and associated outcomes. | PSNet
     psnet.ahrq.gov/issue/high-reliability-organization-framework-health-care-multiyear-implementation-strategy-and
     November 17, 2021 - Study A high-reliability organization framework for health care: a multiyear implementation strategy and associated outcomes. Citation Text: Sculli GL, Pendley-Louis R, Neily J, et al. A high-reliability organization framework for health care: a multiyear implementation strategy and asso…

357. Which Line: Ordering Provider or Proceduralist? | PSNet
     psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
     September 16, 2015 - errors in one series ( 1 ) and present in up to 22% of radiology reports.( 2 ) Communication errors occur

358. Normal Accidents: Living with High-Risk Technologies. | PSNet
     psnet.ahrq.gov/issue/normal-accidents-living-high-risk-technologies
     March 06, 2005 - Book/Report Classic Normal Accidents: Living with High-Risk Technologies. Citation Text: Normal Accidents: Living with High-Risk Technologies. Perrow C. Princeton NJ: Princeton University Press; 1999. Copy Citation Save Save to you…

359. Failure to Latch | PSNet
     psnet.ahrq.gov/web-mm/failure-latch
     November 27, 2012 - Continued milk production is dependent upon regular and thorough milk removal, which does not occur when

360. The Other Side | PSNet
     psnet.ahrq.gov/web-mm/other-side
     May 01, 2007 - much higher than the rates quoted.( 4,5 ) Analyses of wrong site surgery suggest that problems may occur … The guidelines systematically address each point where problems can occur.( 7,8 ) More detailed information