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Total Results: 1,064 records

Showing results for "occur".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33585/psn-pdf
    March 15, 2025 - Like any procedure that requires close coordination with a multidisciplinary team, errors that occur

  2. Human Factors Engineering | PSNet

    psnet.ahrq.gov/primer/human-factors-engineering
    December 15, 2024 - Resiliency efforts Given that unexpected events are likely to occur, attention needs to be given to their

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39960/psn-pdf
    September 19, 2016 - Respectful Management of Serious Clinical Adverse Events. Second Edition. September 19, 2016 Conway J, Federico F, Stewart K, Campbell MJ. Cambridge, MA: Institute for Healthcare Improvement; 2011. https://psnet.ahrq.gov/issue/respectful-management-serious-clinical-adverse-events-second-edition This white paper e…

  4. Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture | PSNet

    psnet.ahrq.gov/web-mm/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis-and-cuff-rupture
    March 15, 2023 - sedation, and decreased risk of ventilator-associated pneumonia. 5 Complications from tracheostomy can occur … blood flow at cuff pressures over 50 cm H 2 0. 15 Stenosis, fistulas, and other tracheal injuries can occur

  5. Pharmacist's Role in Medication Safety | PSNet

    psnet.ahrq.gov/primer/pharmacists-role-medication-safety
    March 14, 2018 - Background As discussed in the related primer on medication error , adverse drug events occur when exposure

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49801/psn-pdf
    August 01, 2017 - As Reason's Swiss Cheese Model of failure (1) demonstrates, major errors can occur in health care settings—including … Patient deterioration in the perioperative period may occur slowly, and early recognition requires not

  7. The Perils of Cross Coverage | PSNet

    psnet.ahrq.gov/web-mm/perils-cross-coverage
    September 22, 2010 - reduce resident duty hours, the above case is, and may continue to be, an example of the harm that can occur … confidence in handoffs.( 17 ) Peers can serve as a natural and powerful conduit for evaluation to occur

  8. A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis | PSNet

    psnet.ahrq.gov/web-mm/cognitive-and-communication-blind-spot-contributes-permanent-paralysis
    January 13, 2010 - effective communication between health care providers Explain some of the reasons that cognitive errors occur … However, communication errors can occur even in an environment of mutual respect and cooperation, so

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46226/psn-pdf
    October 29, 2017 - Eliciting the functional processes of apologizing for errors in health care: developing an explanatory model of apology. October 29, 2017 Prothero MM, Morse JM. Eliciting the Functional Processes of Apologizing for Errors in Health Care: Developing an Explanatory Model of Apology. Glob Qual Nurs Res. 2017;4:233339…

  10. Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts. | PSNet

    psnet.ahrq.gov/web-mm/overdose-gabapentin-and-oxycodone-patient-end-stage-renal-disease-case-appropriate
    June 24, 2020 - Less than 10% of the parent compound is excreted unchanged in the urine, and toxicity can occur due to

  11. Near Miss With Neonate | PSNet

    psnet.ahrq.gov/web-mm/near-miss-neonate
    August 15, 2018 - designed to help clinicians navigate GBS management more effectively, there are situations in which errors occur

  12. The Role of Undergraduate Nursing Education in Patient Safety | PSNet

    psnet.ahrq.gov/perspective/role-undergraduate-nursing-education-patient-safety
    November 27, 2023 - Another big change is the feedback and assessment that must occur frequently across the entire curriculum … If it’s something that’s high risk and may not occur frequently, hopefully it would be done in a simulated … We don’t want errors to occur, but graduates can be better prepared to address them through learning

  13. In Conversation with... Joan Stanley about The Role of Undergraduate Nursing Education in Patient Safety | PSNet

    psnet.ahrq.gov/perspective/conversation-joan-stanley-about-role-undergraduate-nursing-education-patient-safety
    November 27, 2023 - Another big change is the feedback and assessment that must occur frequently across the entire curriculum … If it’s something that’s high risk and may not occur frequently, hopefully it would be done in a simulated … We don’t want errors to occur, but graduates can be better prepared to address them through learning

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35716/psn-pdf
    July 10, 2008 - Adherence to black box warnings for prescription medications in outpatients. July 10, 2008 Lasser KE, Seger DL, Yu T, et al. Adherence to black box warnings for prescription medications in outpatients. Arch Intern Med. 2006;166(3):338-44. https://psnet.ahrq.gov/issue/adherence-black-box-warnings-prescription-medic…

  15. Unexplained Apnea Under Anesthesia | PSNet

    psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia
    December 01, 2005 - medication and syringe labels, the occasional failure to do so represents an expected “slip,” more likely to occur

  16. Handoffs and Handovers | PSNet

    psnet.ahrq.gov/glossary/handoffs-and-handovers
    September 13, 2021 - Handoffs and Handovers September 13, 2021 Anonymous (not verified) See Primer . The process when one health care professional updates another on the status of one or more patients for the purpose of taking over their care. Typical examples involve a physician who has been on call overnight telling an incoming …

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34769/psn-pdf
    March 28, 2005 - The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA. March 28, 2005 Vaughan D. Chicago, IL: University of Chicago Press; 1996. ISBN 9780226851754. https://psnet.ahrq.gov/issue/challenger-launch-decision-risky-technology-culture-and-deviance-nasa A model of root cause analysis on a syste…

  18. Where Does Risk-Adjusted Mortality Fit Into a Safety Measurement Program? | PSNet

    psnet.ahrq.gov/perspective/where-does-risk-adjusted-mortality-fit-safety-measurement-program
    March 01, 2015 - contend R-AHMRs shed public light on unsafe hospitals and spur them on to improve much faster than would occur … Our motto was that Bristol should never occur again.

  19. Sick and Pregnant | PSNet

    psnet.ahrq.gov/web-mm/sick-and-pregnant
    August 25, 2021 - the patient's chart.( 4 ) Medication errors related to sound-alike, look-alike drugs (SALAD) can occur

  20. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough | PSNet

    psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
    September 01, 2003 - inside me. " The second case illustrates the consequences of process failures when multiple errors occur
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