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Total Results: 4,231 records

Showing results for "occurred".

21. Medication errors in the care transition of trauma patients | PSNet
    psnet.ahrq.gov/issue/medication-errors-care-transition-trauma-patients
    September 02, 2020 - This observational, descriptive, prospective study comprises an analysis of the medication errors that occurred … Results indicate that most medication errors occurred in the trauma unit and 64.2% of these types of

22. Enteral nutrition: an underappreciated source of patient safety events. | PSNet
    psnet.ahrq.gov/issue/enteral-nutrition-underappreciated-source-patient-safety-events
    February 01, 2023 - reported events were classified as "care management events," eg, incorrect rate or dosage; 31% of errors occurred … during administration ; and 28% occurred during monitoring.

23. The patients' perspective: hematological cancer patients' experiences of adverse events as part of care. | PSNet
    psnet.ahrq.gov/issue/patients-perspective-hematological-cancer-patients-experiences-adverse-events-part-care
    December 01, 2019 - In this study of oncology patients, more than one quarter perceived an adverse event had occurred. … While most were informed soon after the event occurred and given an explanation, fewer than half were

24. Identifying health information technology usability issues contributing to medication errors across medication process stages. | PSNet
    psnet.ahrq.gov/issue/identifying-health-information-technology-usability-issues-contributing-medication-errors
    November 03, 2021 - event reports to identify the type of medication error , the stage in the process in which the error occurred … Errors in dosing were the most frequent type, and occurred during ordering or reviewing.

25. 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

26. 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.

27. 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

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. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. Woman who died at Alta Bates may be victim of medical error not medication mistake. | PSNet
    psnet.ahrq.gov/issue/woman-who-died-alta-bates-may-be-victim-medical-error-not-medication-mistake
    March 23, 2011 - This newspaper article reports how a medical error, which occurred during a nursing strike, resulted

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. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/44760/psn-pdf
    July 10, 2024 - strategy to improve respectful and effective discussions with patients and families after harm has occurred