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Total Results: 4,038 records

Showing results for "occurred".

161. Family of woman who died after a medical error joins hospital's safety panel. | PSNet
     psnet.ahrq.gov/issue/family-woman-who-died-after-medical-error-joins-hospitals-safety-panel
     May 13, 2020 - family became involved with patient safety, serving on an advisory council at the hospital where it occurred

162. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49512/psn-pdf
     May 01, 2006 - The first error (or series of errors) occurred 2 weeks prior to admission when the staff in the ED who … The next group of errors occurred when the patient was admitted. … The final set of errors occurred prior to the patient receiving spinal anesthesia. … such as cardiac arrest and neurological complications.(9) The institution at which this adverse event occurred … process of identifying and labeling radiographs should be reviewed to discover exactly how the errors occurred

163. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39675/psn-pdf
     January 19, 2011 - This review of rapid response system calls to an inpatient hemodialysis unit found that many events occurred

164. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42071/psn-pdf
     February 27, 2013 - measure the impact of such misidentification, the findings raise concern that diagnostic errors may have occurred

165. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38869/psn-pdf
     August 19, 2009 - Approximately 1 in 60 prescriptions for parenteral nutrition resulted in a medication error, most of which occurred

166. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37132/psn-pdf
     June 14, 2011 - Most errors occurred at the transcription stage, and a substantial proportion were attributed to poor

167. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/863747/psn-pdf
     March 06, 2024 - These near-miss events generally occurred in five clinical scenarios – high-risk social situations (

168. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73066/psn-pdf
     March 24, 2021 - The most common process failures contributing to patient harm occurred during order entry/transcription

169. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/61016/psn-pdf
     October 14, 2020 - Cardiac arrest and respiratory events occurred most frequently and largely affected very young children

170. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60556/psn-pdf
     June 03, 2020 - smart-pumps; post-implementation 27% of errors were attributed to the technology and would not have occurred

171. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73109/psn-pdf
     April 07, 2021 - This study analyzed 797 surgical never events that occurred from April 2012 to February 2020 in the

172. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/836854/psn-pdf
     April 06, 2022 - Higher discrepancies occurred with respiratory and analgesic medications, underscoring the importance

173. Hindsight Bias | PSNet
     psnet.ahrq.gov/glossary/hindsight-bias
     September 13, 2021 - the phrase "but for," as in "but for these errors in judgment, this terrible outcome would not have occurred

174. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867392/psn-pdf
     December 18, 2024 - AI detected five errors (compared with one error pre- implementation), four of which occurred when the

175. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36027/psn-pdf
     March 28, 2011 - medical-injuries-among-hospitalized-children This AHRQ–funded study applied new screening criteria to capture health care injuries that occurred

176. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37224/psn-pdf
     December 15, 2011 - Unintentional medication errors, including taking the prescribed medication at the wrong dose or time, occurred

177. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46648/psn-pdf
     March 14, 2018 - The majority of errors occurred during the compounding or dispensing and administration stages.

178. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43813/psn-pdf
     January 20, 2015 - An adverse event was present in 12% of return visits that occurred within 72 hours of the initial visit

179. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41000/psn-pdf
     December 14, 2011 - study found that the medication errors identified by an emergency department pharmacist primarily occurred

180. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34668/psn-pdf
     June 06, 2018 - from the Institute for Safe Medication Practices informing readers of a fatal medication error that occurred