Results

Total Results: 1,064 records

Showing results for "occur".

381. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event | PSNet
     psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event
     July 01, 2017 - estimating risk, the best information available indicates that most transfusions to the wrong patient occur … involved, per CLIA, is required in the transfusion services laboratory when significant deviations occur

382. Verbal Orders and Medication Overrides: A Dangerous Combination | PSNet
     psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination
     September 27, 2023 - Bourgeois, OD, MD This case highlights the potential for medication errors and patient harm to occur … pharmacist review prior to medication selection. 6 It would be more likely for a wrong-drug error to occur

383. EMS Perils from Hospital Overcrowding | PSNet
     psnet.ahrq.gov/web-mm/ems-perils-hospital-overcrowding
     November 25, 2020 - reasonable medical probability, that no material deterioration of the condition is likely to result from or occur … and EDs have the capacity to receive ambulance patients without delay, safe transitions of care can occur

384. Safety Culture in EMS | PSNet
     psnet.ahrq.gov/perspective/safety-culture-ems
     May 26, 2021 - Safety Culture in EMS May 26, 2021  Also Read the Conversation View more articles from the same authors. Citation Text: Cebollero C, Fitall E, Hall KK, et al. Safety Culture in EMS. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US…

385. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation. | PSNet
     psnet.ahrq.gov/web-mm/open-wider-failure-use-interpreter-results-fractured-teeth-and-hypoxia-during-simple
     January 29, 2021 - to the potential for communication problems when providing care for our patients. 1,2 Difficulties occur … patient safety among LEP patients, as well as processes to analyze medical errors and near misses that occur

386. In Conversation with...Allan Frankel, MD | PSNet
     psnet.ahrq.gov/perspective/conversation-withallan-frankel-md
     July 01, 2006 - accurate when you know how human beings err and they're working in a complex system, the fact that events occur … It has a system in place to fairly consider the actions of clinicians when incidents occur, often using

387. Key Issues in Developing a Successful Hospital Safety Program | PSNet
     psnet.ahrq.gov/perspective/key-issues-developing-successful-hospital-safety-program
     July 01, 2006 - It has a system in place to fairly consider the actions of clinicians when incidents occur, often using … accurate when you know how human beings err and they're working in a complex system, the fact that events occur

388. Patient Safety Events and the Role of Patient Safety Organizations During the COVID-19 Pandemic | PSNet
     psnet.ahrq.gov/perspective/patient-safety-events-and-role-patient-safety-organizations-during-covid-19-pandemic
     January 12, 2022 - additional standardized protocols and resources for implementation, should additional surge periods occur

389. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/846170/psn-pdf
     March 15, 2023 - addition to opportunities for an improved patient counseling process, both cases reflect errors that occur … place so that pharmacists are aware of what to do in certain situations where dispensing errors may occur

390. Timely diagnosis of esophageal perforation | PSNet
     psnet.ahrq.gov/web-mm/timely-diagnosis-esophageal-perforation
     September 27, 2023 - Timely diagnosis of esophageal perforation Citation Text: Utter GH, Cooke DT. Timely diagnosis of esophageal perforation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: Google Scholar BibTeX …

391. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866589/psn-pdf
     August 28, 2024 - Developing a process to measure actual harm from medication errors in paediatric inpatients: from design to implementation. August 28, 2024 Mumford V, Raban MZ, Li L, et al. Developing a process to measure actual harm from medication errors in paediatric inpatients: from design to implementation. Br J Clin Pharmac…

392. Medication Reconciliation | PSNet
     psnet.ahrq.gov/primer/medication-reconciliation
     March 15, 2025 - Although most of these changes are intentional, unintended changes occur frequently for a variety of

393. Periodic Issue | PSNet
     psnet.ahrq.gov/periodic-issue/periodic-issue-473
     March 25, 2025 - systems are a core strategy to ensure safe care for hospitalized patients should unexpected deterioration occur

394. In Conversation with...Richard Ricciardi about Office-Based Patient Safety | PSNet
     psnet.ahrq.gov/perspective/conversation-withrichard-ricciardi-about-office-based-patient-safety
     January 31, 2024 - Ric Ricciardi: Those problems are important and occur every day in large numbers. … 3 Office-based settings appear to be safer than hospital settings, but patient safety incidents do occur … be approached in similar ways in both acute and office-based settings, for example patient falls can occur

395. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866902/psn-pdf
     October 09, 2024 - Why do acute healthcare staff behave unprofessionally towards each other and how can these behaviours be reduced? A realist review. October 9, 2024 Aunger JA, Abrams R, Westbrook JI, et al. Why do acute healthcare staff behave unprofessionally towards each other and how can these behaviours be reduced? A realist r…

396. Patient Safety Events Involving Opioid Dose Stacking | PSNet
     psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking
     July 08, 2022 - Dose stacking can occur in a multitude of ways and is typically a consequence of patient-reported inadequate … Dose stacking can also occur when a patient receives opioids via numerous sources or routes.

397. Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis. | PSNet
     psnet.ahrq.gov/web-mm/strongyloides-hidden-traveler-and-potentially-lethal-missed-diagnosis
     August 25, 2021 - Ivermectin is a curative treatment for Strongyloides , but re-infection can occur if there is ongoing

398. Transfusion Overload | PSNet
     psnet.ahrq.gov/web-mm/transfusion-overload
     September 23, 2020 - "Over-transfusion" can occur in the clinical setting where there is good-quality, randomized evidence

399. Multifactorial Medication Mishap | PSNet
     psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
     September 01, 2016 - SPOTLIGHT CASE Multifactorial Medication Mishap Citation Text: Yang A. Multifactorial Medication Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNot…

400. Falling Through the Crack (in the Bedrails) | PSNet
     psnet.ahrq.gov/web-mm/falling-through-crack-bedrails
     February 19, 2020 - "( 3 ) Patient falls occur in approximately 2% of hospital stays, and in the United States up to 1 million … Patient falls in the ICU are less frequent than on acute care or intermediate care units, but they still occur