Results

Total Results: over 10,000 records

Showing results for "occur".

221. Spotlight
     psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_stable_airway_slides_final.pptx
     January 01, 2024 - occlusion, as in this case. 15 15 Tracheostomy Management (4) Complications of tracheostomy can occur … can cause skin breakdown and require a plan for removal.5,7  Obstruction of the tracheostomy tube can occur … surgically placed tubes, due to healing times.1,15  If the type of placement is unknown, no change should occur … need to be familiar with what low versus high priority alarms sound like and what to do when these occur … a plan for the next tracheostomy change, an explanation of complications that have occurred or may occur

222. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/854897/psn-pdf
     October 31, 2023 - These errors can occur at any stage in the medication use process, from prescribing to administration … To understand how such medication errors can occur, it is helpful to review James Reason’s Swiss Cheese … According to Reason, accidents within most complex systems (e.g., healthcare) occur from the breakdown … False alerts occur without any actual event, whereas nonactionable alerts result from events that lack … initial data entry to final medication administration, had vulnerabilities that allowed the error to occur

223. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/853773/psn-pdf
     September 27, 2023 - Wrong site or wrong patient errors, as in the case above, reportedly occur in approximately 1 in every … Despite system changes to prevent medical errors and “never events,” they will likely continue to occur … When “never events” occur, as in this case, it is important to disclose the error clearly, support the … It is expected that hospital staff perform a root cause analysis when such events occur, clearly disclose … When “never events” or sentinel events occur, the impact on the health care providers should be taken

224. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/846756/psn-pdf
     March 29, 2023 - the majority of studies as administration greater than 60 minutes before or after the scheduled time) occur

225. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/837974/psn-pdf
     August 31, 2022 - healthcare balances organizational and individual responsibility and accountability when medical errors occur

226. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/838029/psn-pdf
     September 07, 2022 - emergency-preparedness-be-ready-unanticipated-electronic-health-record-ehr- downtime Unanticipated health information system downtime can occur

227. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60949/psn-pdf
     September 23, 2020 - can assign accountability appropriately while encouraging disclosure and improvement when mistakes occur

228. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73295/psn-pdf
     May 19, 2021 - bupivacaine- hydrochloride-injection-usp Anesthesia medications can be high risk should dosing errors occur

229. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/846153/psn-pdf
     March 15, 2023 - Fires were most likely to occur during upper aerodigestive tract and head and neck surgeries; these

230. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/837300/psn-pdf
     June 01, 2022 - https://psnet.ahrq.gov/issue/surgery-itself-risk-factor-patient Preventable adverse events (AE) can occur

231. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/838312/psn-pdf
     October 12, 2022 - causes-adverse-events-home-mechanical-ventilation-nursing-perspective Hospital-level care at home can reduce cost and hospital readmissions, but adverse events still occur

232. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/852803/psn-pdf
     August 23, 2023 - potential for data breaches and reduce their impact on care delivery and processes should cyberattacks occur

233. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73181/psn-pdf
     April 28, 2021 - effectiveness of medical emergency teams (MET) has been widely researched, critical incidents that occur

234. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35152/psn-pdf
     July 13, 2005 - https://psnet.ahrq.gov/issue/not-what-doctor-ordered This article reports on the types of errors that occur

235. AHRQ QI Quality Indicators Brochire (pdf file)
     qualityindicators.ahrq.gov/Downloads/Modules/V2022/AHRQ_QI_Full_Brochure.pdf
     March 28, 2023 - • Hospital-level indicators detect potential safety problems that occur during a patient's hospital … • They include hospital-level indicators to detect potential safety problems that occur during a

236. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/865877/psn-pdf
     May 15, 2024 - The revised framework identifies critical points where communication breakdowns are likely to occur

237. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/860732/psn-pdf
     April 16, 2024 - retained-swabs-following-invasive-procedures-themes-identified-review-nhs- serious-incident Retained surgical items are never events that continue to occur

238. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36604/psn-pdf
     June 04, 2024 - 15th-annual-public-report The National Quality Forum has defined 29 never events—patient safety problems that should never occur

239. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40971/psn-pdf
     June 01, 2012 - iatrogenic-psychological-harm This review discusses iatrogenic psychological harm, including how it may occur

240. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/847043/psn-pdf
     April 05, 2023 - evidence-synthesis-perioperative-handoffs-call-balanced-sociotechnical- solutions Multiple handoffs occur