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Total Results: 4,038 records

Showing results for "occurred".

21. Relationships between medications used in a mental health hospital and types of medication errors: a cross-sectional study over an 8-year period. | PSNet
    psnet.ahrq.gov/issue/relationships-between-medications-used-mental-health-hospital-and-types-medication-errors
    November 29, 2023 - This study used 8 years of medication records to identify when in the medication process the error occurred … Nearly one-third of errors were wrong dose and occurred in the prescribing stage.

22. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/37446/psn-pdf
    January 06, 2017 - Investigators discovered that inpatient warfarin- related errors occurred most frequently during transcription … /documentation and administration, while outpatient errors occurred most frequently during prescribing

23. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/36200/psn-pdf
    February 15, 2011 - Prior research revealed that patients wanted the physicians to apologize for the error, explain how it occurred … Approximately half of respondents declined to explain how the error occurred or discuss specific plans

24. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/39402/psn-pdf
    August 08, 2010 - A fatal vincristine error that occurred in the United Kingdom was the subject of a detailed investigation … preventing-vincristine-administration-errors https://psnet.ahrq.gov/issue/external-inquiry-adverse-incident-occurred-queens-medical-centre-nottingham

25. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/41522/psn-pdf
    December 02, 2014 - resulted in patient harm in the outpatient setting, and this study found that more than 250 such errors occurred … Although pharmacists intercepted nearly half the errors, more than one-third occurred at the time of

26. Omission of high-alert medications: a hidden danger. | PSNet
    psnet.ahrq.gov/issue/omission-high-alert-medications-hidden-danger
    January 11, 2017 - The investigation found that more than half of errors occurred during the administration process, and … September 27, 2016 External Inquiry into the adverse incident that occurred at Queen's

27. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/40819/psn-pdf
    January 07, 2015 - Although fewer overall errors occurred with the new system, the reduction in administration errors occurred

28. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/36342/psn-pdf
    March 02, 2011 - Diagnostic errors resulting in patient harm occurred in 181 cases, chiefly consisting of missed or delayed … As with prior studies  using chart review, reviewer's agreement on whether an error occurred was only

29. Preventable harm occurring to critically ill children. | PSNet
    psnet.ahrq.gov/issue/preventable-harm-occurring-critically-ill-children
    September 28, 2010 - Approximately one error occurred for every five patient-days, although more than three-quarters of these

30. Choosing your words carefully: how physicians would disclose harmful medical errors to patients. | PSNet
    psnet.ahrq.gov/issue/choosing-your-words-carefully-how-physicians-would-disclose-harmful-medical-errors-patients
    February 16, 2011 - Prior research revealed that patients wanted the physicians to apologize for the error, explain how it occurred … Approximately half of respondents declined to explain how the error occurred or discuss specific plans

31. How useful are voluntary medication error reports? The case of warfarin-related medication errors. | PSNet
    psnet.ahrq.gov/issue/how-useful-are-voluntary-medication-error-reports-case-warfarin-related-medication-errors
    May 27, 2011 - Investigators discovered that inpatient warfarin-related errors occurred most frequently during transcription … /documentation and administration, while outpatient errors occurred most frequently during prescribing

32. From physician intent to the pharmacy label: prevalence and description of discrepancies from a cross-sectional evaluation of electronic prescriptions. | PSNet
    psnet.ahrq.gov/issue/physician-intent-pharmacy-label-prevalence-and-description-discrepancies-cross-sectional
    July 22, 2020 - The investigators found that errors occurred at each stage of the process, with a small but significant … These errors often occurred when providers entered free-text instructions into the e-prescribing system

33. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/42968/psn-pdf
    February 26, 2014 - The investigators found that errors occurred at each stage of the process, with a small but significant … These errors often occurred when providers entered free-text instructions into the e-prescribing system

34. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.239_slideshow.ppt
    May 01, 2011 - Disclosure Discussing medical errors with patients is challenging Patients want to know when errors have occurred … Disclosure respects patient autonomy In general, patients want to learn about harmful errors that have occurred … Additional factors complicate this case: The disclosing physicians did not make the error The error occurred … the care provided Examination of the possible error might involve a root cause analysis If an error occurred … two hospitals should have had an open dialogue about the case If they determined that a clear error occurred

35. Multimodal system designed to reduce errors in recording and administration of drugs in anaesthesia: prospective randomised clinical evaluation. | PSNet
    psnet.ahrq.gov/issue/multimodal-system-designed-reduce-errors-recording-and-administration-drugs-anaesthesia
    September 26, 2012 - Although fewer overall errors occurred with the new system, the reduction in administration errors occurred

36. Adverse Events, Near Misses, and Errors | PSNet
    psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors
    March 30, 2022 - independently reviewed by two clinically experienced reviewers in order to determine whether an adverse event occurred … When an adverse event occurred, reviewers also may disagree about whether the event was preventable. … Important subcategories of adverse events include: Preventable adverse events : those that occurred due … could have been less harmful if care had been different; Adverse events due to negligence : those that occurred

37. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/49395/psn-pdf
    April 01, 2003 - references additional 5% experience a potential ADE (ie, the error reached the patient, but no harm occurred … reported similar rates of ADEs, though rates of potential ADEs were even higher.(5) Most potential ADEs occurred … (Figure 1, Figure 2) The error in this case occurred independent of prescription legibility. … confusion between ‘dose’ and ‘day,’ due to ambiguous use of the abbreviation “d” in “mg/kg/d,” could have occurred … ensures that orders are complete and in a standard format, eliminating ambiguous dosing orders as occurred

38. Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims. | PSNet
    psnet.ahrq.gov/issue/missed-and-delayed-diagnoses-ambulatory-setting-study-closed-malpractice-claims
    October 26, 2010 - Diagnostic errors resulting in patient harm occurred in 181 cases, chiefly consisting of missed or delayed … As with prior studies  using chart review, reviewer's agreement on whether an error occurred was only

39. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.64_slideshow.ppt
    June 01, 2004 - dopt=Abstract&list_uids=12477944 Disclosure: What Patients Want Jargon-free statement that error occurred … discussing such issues Physician may choose words carefully to avoid explicitly stating that an error occurred … malpractice claims Others argue that the reason few injured patients sue is because they are unaware error occurred … should be disclosed to patients Error disclosure should include an explicit statement that an error occurred

40. Misread Label | PSNet
    psnet.ahrq.gov/web-mm/misread-label
    August 28, 2024 - On face value, it is almost impossible to imagine how this could have occurred. … In addition to exploring why the error occurred at the level of individuals at the "sharp end," such … effectively, but involves interviewing staff involved to identify care management problems and why each occurred … Although physicians disclosed the adverse event, they often avoided stating that an error had occurred