Results

Total Results: 4,032 records

Showing results for "occurred".

1341. Misadventures in Health Care: Inside Stories. | PSNet
      psnet.ahrq.gov/issue/misadventures-health-care-inside-stories
      July 06, 2011 - January 6, 2015 External Inquiry into the adverse incident that occurred at Queen's Medical

1342. Inadvertent Castration | PSNet
      psnet.ahrq.gov/web-mm/inadvertent-castration
      October 27, 2010 - We know nothing of this surgeon's training, the time of day the injury occurred, or pertinent environmental … This procedure may have occurred in a hospital where an urologist was not immediately available, a situation … wrong-site surgery.( 8,9 ) This patient had his testicle surgically removed, but similar disasters have occurred

1343. Milliliters vs. Milligrams | PSNet
      psnet.ahrq.gov/web-mm/milliliters-vs-milligrams
      September 01, 2004 - The second error in this case occurred when the nurse administered the entire contents of the 20-mg multidose … While this error may have occurred because the printed instructions were not followed by the nurse, it … Bates, and colleagues reported that the most common errors in the medication use process in children occurred

1344. Missing ECG and Missed Diagnosis Lead to Dangerous Delay | PSNet
      psnet.ahrq.gov/web-mm/missing-ecg-and-missed-diagnosis-lead-dangerous-delay
      March 01, 2015 - results were notable for an elevated troponin level, suggesting that significant myocardial damage had occurred … artery in under 90 minutes.( 5 ) In the case described above, a critical communication breakdown occurred … regarding the results of the initial ECG tracing and the failure of transmission of the initial tracing occurred

1345. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49539/psn-pdf
      June 01, 2007 - references https://psnet.ahrq.gov//#references https://psnet.ahrq.gov//#references error actually occurred … Ironically, the hearing loss that occurred is apparently less prevalent following general anesthesia

1346. Achieving Safe Health Care: Delivery of Safe Patient Care at Baylor Scott & White Health. | PSNet
      psnet.ahrq.gov/issue/achieving-safe-health-care-delivery-safe-patient-care-baylor-scott-white-health
      October 11, 2016 - October 14, 2015 External Inquiry into the adverse incident that occurred at Queen's

1347. Engineering Patient Safety in Radiation Oncology: University of North Carolina's Pursuit for High Reliability and Value Creation. | PSNet
      psnet.ahrq.gov/issue/engineering-patient-safety-radiation-oncology-university-north-carolinas-pursuit-high
      May 04, 2016 - October 23, 2013 External Inquiry into the adverse incident that occurred at Queen's

1348. Improving patient safety by taking systems seriously. | PSNet
      psnet.ahrq.gov/issue/improving-patient-safety-taking-systems-seriously
      April 17, 2013 - December 9, 2014 External Inquiry into the adverse incident that occurred at Queen's

1349. Patient Safety in Private Hospitals: the Known and the Unknown Risk. | PSNet
      psnet.ahrq.gov/issue/patient-safety-private-hospitals-known-and-unknown-risk
      June 18, 2013 - Related Resources From the Same Author(s) External Inquiry into the adverse incident that occurred

1350. What doctors can learn from the factory floor. | PSNet
      psnet.ahrq.gov/issue/what-doctors-can-learn-factory-floor
      June 13, 2011 - August 9, 2013 External Inquiry into the adverse incident that occurred at Queen's Medical

1351. Health Care Comes Home: The Human Factors. | PSNet
      psnet.ahrq.gov/issue/health-care-comes-home-human-factors
      June 08, 2011 - February 10, 2015 External Inquiry into the adverse incident that occurred at Queen's

1352. Juran's Quality Handbook. 5th ed. | PSNet
      psnet.ahrq.gov/issue/jurans-quality-handbook-5th-ed
      October 18, 2017 - July 8, 2013 External Inquiry into the adverse incident that occurred at Queen's Medical

1353. Establishing a culture for patient safety - the role of education. | PSNet
      psnet.ahrq.gov/issue/establishing-culture-patient-safety-role-education
      August 23, 2017 - December 30, 2014 External Inquiry into the adverse incident that occurred at Queen's

1354. Patient Safety 2030. | PSNet
      psnet.ahrq.gov/issue/patient-safety-2030
      April 13, 2016 - February 26, 2014 External Inquiry into the adverse incident that occurred at Queen's

1355. A model of chemotherapy education for novice oncology nurses that supports a culture of safety. | PSNet
      psnet.ahrq.gov/issue/model-chemotherapy-education-novice-oncology-nurses-supports-culture-safety
      September 24, 2010 - November 30, 2016 External Inquiry into the adverse incident that occurred at Queen's

1356. Which Line: Ordering Provider or Proceduralist? | PSNet
      psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
      September 16, 2015 - inspection, the least effective approach, adverse events are captured after the error or issue has occurred … For this case, self-check would have occurred if the ordering physician had confirmed the order was for … Control means a system that captures when an error has occurred and blocks propagation, preventing patient … This type of successive check might well have identified the error before the adverse event occurred.

1357. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49681/psn-pdf
      April 01, 2013 - As occurred in this case, multiple failures across the PN-use process are usually identified in retrospect … Multiple warnings occurred daily with this patient's PN order, and ignoring them contributed to the error … One PN-related fatality occurred when an infant received a 1000-fold excess of zinc because of a mix-up … per day in another pediatric case was identified during PN infusion but before any adverse effect occurred

1358. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49419/psn-pdf
      October 01, 2003 - In the present case, as far as one can tell, no problems occurred in the routine biopsy, labeling, and … The wrong site surgery occurred because the surgeon remembered, incorrectly, that he had biopsied the … Patients who have not experienced errors report that, if a harmful error occurred in their treatment

1359. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49451/psn-pdf
      June 01, 2004 - This particular event occurred on a Friday, as the physician left for the weekend. … follow-up on an important radiographic or laboratory test result) may reduce the risk of lapses such as occurred … That appears to have occurred here since laboratory staff called infection control staff, who called

1360. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49593/psn-pdf
      October 01, 2009 - nasal cavity (so that its external portion was no longer extruding from the nose), but presumably this occurred … trachea and right bronchus.(1) One death was reported in a case with an aspirated airway, although this occurred … Nonetheless, some discussion regarding the NPA should have occurred prior to intubation, since the anesthesiologist