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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39730/psn-pdf
    December 21, 2014 - of Joint Commission’s Universal Protocol and implementation of briefings, these events continue to occur
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39315/psn-pdf
    March 21, 2017 - risk-managers-physicians-and-disclosure-harmful-medical-errors Patients desire and deserve disclosure of any errors that occur
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45356/psn-pdf
    May 09, 2017 - psnet.ahrq.gov/issue/screening-medication-errors-using-outlier-detection-system Medication errors continue to occur
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39404/psn-pdf
    March 31, 2010 - suggested that wrong-site procedures may be more common than previously thought, since such errors can occur
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40038/psn-pdf
    December 23, 2016 - are not, and prior research has shown that a significant proportion of inpatient suicide attempts occur
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42230/psn-pdf
    October 06, 2016 - administration are one of the most common types of medication errors, with one study showing that they occur
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44831/psn-pdf
    January 27, 2016 - Trigger tools can help to identify opportunities for patient harm and measure adverse events that occur
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46361/psn-pdf
    May 23, 2018 - Handoffs can occur within or across settings of care (e.g., between two clinicians in the same hospital
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42575/psn-pdf
    September 26, 2016 - inevitable in the busy clinical environment and may contribute to preventable harm, particularly if they occur
  10. psnet.ahrq.gov/web-mm/discharge-against-medical-advice
    July 01, 2017 - four times more likely than non-users to leave AMA, and AMA discharges were three times more likely to occur … In summary, this case illustrates numerous points at which preventable errors can occur when a patient … provider-to-provider communication that would have identified the patient’s lack of capacity did not occur … Take-Home Points Approximately 1%-2% of hospital discharges occur AMA.
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49548/psn-pdf
    October 01, 2007 - function test abnormalities are not uncommon (4), and diffuse abdominal pain and hepatosplenomegaly may occur … Thyroid storm may also occur in postoperative patients ("surgical storm") or may be precipitated by … iodine-containing contrast dye to aggravate the woman's thyrotoxic state as this would typically require weeks to occur
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33811/psn-pdf
    June 01, 2016 - the use of SBAR (situation, background, assessment, recommendation), yet medical errors continue to occur … They are truly affected by the tragedies that occur in the literature.
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39777/psn-pdf
    November 04, 2012 - identify errors, deaths, and costs, and found that more than 1.5 million preventable adverse events occur
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43904/psn-pdf
    October 13, 2015 - reducing-unacceptable-missed-doses-pharmacy-assistant-supported- medicine-administration Omitted or delayed medication doses occur
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40600/psn-pdf
    September 09, 2011 - Quality Forum first defined a set of never events to highlight significant errors that should never occur
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47876/psn-pdf
    March 27, 2019 - Inadequate communication during handoffs that occur as part of care transitions can contribute to adverse
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45425/psn-pdf
    December 22, 2018 - an excessive number of safety warnings that prescribers must manually override, alert fatigue  may occur
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47058/psn-pdf
    August 20, 2018 - for improving the safety and quality of health care, consistent use of known best practices does not occur
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42900/psn-pdf
    September 19, 2016 - The majority of inpatient suicides occur in psychiatric units, but a prior Joint Commission sentinel
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39822/psn-pdf
    February 17, 2011 - what information to share and how to share it; of course, discussions about individual disclosure occur

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