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Total Results: 4,038 records

Showing results for "occur".

61. Medication Mix-Up Leads to Patient Death | PSNet
    psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
    July 08, 2022 - medical errors are the third most common cause of death behind heart disease and cancer. 2 Errors can occur … hazards are prevented by barriers, but holes in the cheese represent opportunities for an error to occur … and commentary highlight the continual need for improvement, and how serious medication errors can occur … Thus, even if incorrect decisional responses are rare, they occur with sufficient frequency to impact … Workarounds occur within healthcare systems and may lead to deviations from protocols while providing

62. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/857259/psn-pdf
    November 30, 2023 - medical errors are the third most common cause of death behind heart disease and cancer.2 Errors can occur … hazards are prevented by barriers, but holes in the cheese represent opportunities for an error to occur … and commentary highlight the continual need for improvement, and how serious medication errors can occur … Thus, even if incorrect decisional responses are rare, they occur with sufficient frequency to impact … Workarounds occur within healthcare systems and may lead to deviations from protocols while providing

63. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/867676/psn-pdf
    February 26, 2025 - https://psnet.ahrq.gov/primer/responding-patient-safety-events Background Patient safety events that occur … If indicated, early compensation could occur in the form of waiving hospital bills while the healthcare … This especially tends to occur in situations where the healthcare staff bonds with a patient or family

64. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/33561/psn-pdf
    September 15, 2024 - in reference to particularly shocking medical errors—such as wrong-site surgery—that should never occur … However, when Never Events occur, they are devastating to patients and may indicate a fundamental safety … A 2013 study estimated that more than 4000 surgical never events occur yearly in the United States.

65. Primers | PSNet
    psnet.ahrq.gov/primers-0
    March 15, 2025 - records in order to identify errors and adverse events, measure the frequency with which such events occur … records in order to identify errors and adverse events, measure the frequency with which such events occur … Facebook Twitter Linkedin Copy URL Patient safety events that occur … preventable, but health care systems should be able to rapidly identify and treat complications when they occur

66. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/867145/psn-pdf
    November 13, 2024 - issue/technology-education-and-safety-3 Despite consummate efforts to improve safety, errors still occur

67. Addressing Workplace Violence and Creating a Safer Workplace | PSNet
    psnet.ahrq.gov/perspective/addressing-workplace-violence-and-creating-safer-workplace
    October 31, 2023 - tagged PubMedId RIS Download Citation While violence in the workplace can occur … stalking, and sexual harassment. 5 Perpetrators of workplace violence can vary, and violence can occur … we think that certain units may have a patient population that may predispose workplace violence to occur … In recent years, in addition to workplace violence events that may occur in healthcare organizations, … Having reporting systems in place that facilitate the reporting of events when they actually occur is

68. In Conversation with... Cheryl Jones about Addressing Workplace Violence and Creating a Safer Workplace | PSNet
    psnet.ahrq.gov/perspective/conversation-cheryl-jones-about-addressing-workplace-violence-and-creating-safer
    October 31, 2023 - employ large numbers of healthcare professionals, with opportunities for workplace violence events to occur … we think that certain units may have a patient population that may predispose workplace violence to occur … In recent years, in addition to workplace violence events that may occur in healthcare organizations, … challenges with reporting and making it easier for clinicians to report acts of violence when they occur … Having reporting systems in place that facilitate the reporting of events when they actually occur is

69. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/837708/psn-pdf
    July 20, 2022 - psnet.ahrq.gov/issue/without-question Diagnostic errors caused by premature closure and anchoring bias occur

70. Inside a closed-loop medication strategy: medication management targets stages in which errors occur, step by step. | PSNet
    psnet.ahrq.gov/issue/inside-closed-loop-medication-strategy-medication-management-targets-stages-which-errors
    January 30, 2013 - Inside a closed-loop medication strategy: medication management targets stages in which errors occur

71. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/865598/psn-pdf
    April 17, 2024 - medication therapy for transplant patients is complex and has the potential for serious harm when errors occur

72. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/72911/psn-pdf
    March 15, 2021 - nutritional supplements are often overlooked by providers and patients.7     Medication errors may occur … Hospital discharges are one example of a transition of care, and over 35 million hospital discharges occur … The Joint Commission Center for Transforming Healthcare reports that communication breakdowns occur … Breakdowns in patient education can occur when conflicting recommendations are made. … Accountability breakdowns occur when there is no primary provider to take responsibility for assuring

73. Around the Block | PSNet
    psnet.ahrq.gov/web-mm/around-block
    March 04, 2020 - And, perhaps most importantly, how did this series of events occur despite the presence of the warning … Preoperative LMWH Needle placement should occur at least 10-12 hours after the LMWH dose. … avoided in patients administered a dose of LMWH 2 hours preoperatively, because needle placement would occur … The second postoperative dose should occur no sooner than 24 hours after the first dose. … Subsequent LMWH dosing should occur a minimum of 2 hours after catheter removal.

74. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/49476/psn-pdf
    March 02, 2005 - And, perhaps most importantly, how did this series of events occur despite the presence of the warning … list_uids=11342094 https://psnet.ahrq.gov//#references Preoperative LMWH Needle placement should occur … avoided in patients administered a dose of LMWH 2 hours preoperatively, because needle placement would occur … The second postoperative dose should occur no sooner than 24 hours after the first dose. … Subsequent LMWH dosing should occur a minimum of 2 hours after catheter removal.

75. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/45611/psn-pdf
    May 27, 2025 - funding-announcement-projects-targeting-reduction-healthcare-associated- infections Health care–associated infections occur

76. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/867224/psn-pdf
    December 04, 2024 - safety-inpatient-care-surgical-settings-cohort-study Despite decades of safety improvement efforts, surgical complications continue to occur

77. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/861776/psn-pdf
    January 31, 2024 - such as communication and resolution programs to encourage apologies and transparency when errors occur

78. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/49485/psn-pdf
    August 29, 2024 - Though not well appreciated by many clinicians, POVL may occur in relatively healthy patients, even when … AION has been associated primarily with cardiac bypass procedures but can occur during prone spine operations … Peripheral vision is frequently affected, but total blindness may occur as well. … Visual loss secondary to AION has been reported to occur anytime from the immediate postoperative period … count fingers does not preclude the possibility of scotoma or discrete visual field deficits as may occur

79. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/867696/psn-pdf
    March 05, 2025 - are a core strategy to ensure safe care for hospitalized patients should unexpected deterioration occur

80. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/72484/psn-pdf
    November 18, 2020 - focuses on management of, and preparation for, perioperative critical events and rescue should they occur