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Total Results: 4,038 records

Showing results for "occurred".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41215/psn-pdf
    September 04, 2013 - A case of an ultimately fatal adverse event that occurred while a patient was being transported from

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35175/psn-pdf
    June 23, 2009 - overnight-and-postcall-errors-medication-orders This study examined the incidence of prescribing errors that occurred

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40745/psn-pdf
    September 07, 2011 - However, direct verbal communication occurred in only a small minority of cases, and several preventable

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45941/psn-pdf
    March 08, 2017 - Three major insulin administration errors occurred, which led to training and process changes in order

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44402/psn-pdf
    January 22, 2016 - communication-amc-va-end-shift This qualitative analysis found that anticipatory management conversation occurred

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41210/psn-pdf
    January 03, 2017 - case-study-safety-impact-implementing-smart-patient-controlled-analgesic- pumps-tertiary-care After adverse events occurred

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43726/psn-pdf
    September 01, 2016 - This qualitative study found alert overrides occurred most frequently in the emergency department, and

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34799/psn-pdf
    December 23, 2008 - Admissions most frequently occurred in elderly patients and those on diuretics or digoxin.

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37151/psn-pdf
    January 02, 2017 - dissemination of the Joint Commission's “do not use” abbreviation list, errors involving these abbreviations occurred

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46717/psn-pdf
    April 16, 2018 - , the average number of opioid pills per prescription declined, but no increase in refill requests occurred

  11. To LP or Not LP | PSNet

    psnet.ahrq.gov/web-mm/lp-or-not-lp
    February 01, 2018 - Fortunately, no long-term sequelae occurred as a consequence of the errors in care suffered by this patient … Four distinct errors occurred in this case. … The errors in execution made by the original provider likely would not have occurred in less hectic working … laboratory could have been more proactive about clarifying information, but had errors one and two not occurred

  12. Preventing infection from the misuse of vials. | PSNet

    psnet.ahrq.gov/issue/preventing-infection-misuse-vials
    September 11, 2023 - Most outbreaks occurred in hospitals, but a large number of cases also came from outpatient pain management

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33591/psn-pdf
    March 15, 2025 - events so they can review the medical record to determine if an actual or potential adverse event has occurred … Study and other classic studies used fairly blunt triggers, general indications that harm may have occurred

  14. Nil per os orders for imaging: a teachable moment. | PSNet

    psnet.ahrq.gov/issue/nil-os-orders-imaging-teachable-moment
    November 13, 2024 - This case discussion reviews an incident that occurred due to an NPO status order for a patient prior

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42386/psn-pdf
    December 29, 2014 - In particular, time-outs frequently occurred without all team members present.

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39960/psn-pdf
    September 19, 2016 - organizations to have a comprehensive crisis plan in place rather than reacting after events have occurred

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46226/psn-pdf
    October 29, 2017 - and how such conversations can help restore the patient–physician relationship after an error has occurred

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44979/psn-pdf
    April 06, 2016 - The program includes apology, disclosure, and explanation of what occurred as well as financial compensation

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46276/psn-pdf
    August 02, 2017 - Increased rates of opioid prescribing occurred in areas that are not urban, have a greater proportion

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34811/psn-pdf
    March 28, 2005 - Although error rates occurred most in inexperienced physicians, no group was error free.
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