Results

Total Results: 4,038 records

Showing results for "occurred".

1441. 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

1442. 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

1443. 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

1444. 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

1445. 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

1446. 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

1447. 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

1448. 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

1449. 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

1450. 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.

1451. 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

1452. A Potent Medication Administered in a Not So Viable Route | PSNet
      psnet.ahrq.gov/web-mm/potent-medication-administered-not-so-viable-route
      July 20, 2016 - Of these, the majority occurred when vasopressors were given for a very long duration (55.9 ± 68.1 hours … The 2-hour limit was chosen because very few published cases of local tissue injury events occurred within … frame—of 138 published cases of local tissue injury where the duration of infusion was given, only 4 occurred

1453. 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

1454. 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

1455. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.290_slideshow.ppt
      February 01, 2013 - Errors can happen in the final step—the clinician and patient executing a treatment plan That is what occurred … in this case * * Follow-up Errors A number of high-profile cases have occurred in which test

1456. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49509/psn-pdf
      April 01, 2006 - In this case, bleeding occurred despite an ongoing pregnancy; this can happen at some time in the course … If strings cannot be identified, as occurred in this case, sonography is the most effective way to check

1457. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.299_slideshow.ppt
      May 01, 2013 - Error rates generally lower than non-chemotherapy medications Errors with chemotherapy most commonly occurred … This chemotherapy error occurred due to the lack of a high reliability framework and an over-reliance

1458. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49559/psn-pdf
      April 01, 2008 - of isotonic fluid and maintenance of euvolemia can prevent the systemic effects of dehydration that occurred … strict monitoring of serum sodium and plasma osmolality in order to prevent the complications that occurred

1459. 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

1460. 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