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Showing results for "occur".

  1. Assessment of Pediatric Look-Alike, Sound-Alike (LASA) Substitution Errors - Final Report (pdf file)

    digital.ahrq.gov/sites/default/files/docs/publication/r03hs018841-basco-final-report-2013.pdf
    January 01, 2013 - Scope: Medication errors occur frequently in ambulatory prescribing, but less is known about the potential … Methods: 37 practicing pediatricians evaluated published LASA pairs, estimating the harm that might occur … should a patient not receive the intended drug in any LASA pair and the harm that might occur from … However, the substitutions can occur in either direction, meaning that there are actually 3568 pairs … The instructions reminded participants to not estimate the chance that harm would occur.

  2. Nrd2014 (pdf file)

    hcup-us.ahrq.gov/db/nation/nrd/NRD2014.pdf
    December 25, 2022 - HCUP typically allows the day of procedure to occur up to 4 days before the stay began (negative value

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37752/psn-pdf
    May 07, 2019 - been adopted in hospitals to prevent medication errors, but accidents associated with their use still occur

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73327/psn-pdf
    January 25, 2022 - ismp-medication-safety-self-assessmentr-perioperative-settings The perioperative setting is a high-risk area for medication errors, should they occur

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/843322/psn-pdf
    February 01, 2023 - psnet.ahrq.gov/issue/deadly-epidural-delivered-doctor-history-mistakes Active errors are evident when they occur

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73326/psn-pdf
    June 01, 2021 - model was designed to support early error disclosure with patients and families after mistakes in care occur

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838326/psn-pdf
    October 12, 2022 - people-color-long-covid-face-uphill-battle-be-heard Gaslighting women and patients of color is known to occur

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50757/psn-pdf
    December 18, 2019 - psnet.ahrq.gov/issue/university-hospital-hounds-debtors-doctors-say-its-doing-harm Financial harms occur

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851658/psn-pdf
    July 26, 2023 - This article summarizes potential patient harm that can occur during hospitalization for older adults

  10. 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

  11. 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.

  12. Exhibit 2.14. Major Factors that Facilitated Lean Success at Central | Agency for Healthcare Research and Quality

    www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit2-14.html
    November 01, 2014 - Including physicians and hospital department leadership on the team ensured that change could occur and

  13. Sensemaking and Learn from Defects for Perinatal Safety (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.pdf
    May 01, 2017 - Defects 2 • The Learn From Defects Form, which provides a standardized means to assess where defects occur … These conditions are the mistakes that occur without human error. … • Organizational failures occur when decisional elements, such as culture, procedures, and leadership … By doing this, teams are able to assign meaning to the system breakdowns that occur on their L&D unit … defects on the L&D unit, it is important for staff to understand where and how breakdowns in safety occur

  14. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/factraining.html
    September 01, 2017 - Communicate risk changes as they occur. … Improve root cause analyses when adverse events occur. … When will the meeting occur? … How will communication occur with other disciplines to confirm changes in care? … When will the meeting occur?

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853977/psn-pdf
    September 27, 2023 - the British National Health System (NHS) and the factors that allowed continued criminal activity to occur

  16. 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.

  17. 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

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852458/psn-pdf
    June 01, 2019 - patients to engage with their own safety and how to effectively communicate with patients should an error occur

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838027/psn-pdf
    September 07, 2022 - advancing-anticoagulation-stewardship-playbook Warfarin and other anticoagulants are high-alert medications that, if errors occur

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/847057/psn-pdf
    April 05, 2023 - This article discusses medication errors that continue to occur despite established practices that,
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