Results

Total Results: 4,038 records

Showing results for "occurred".

221. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39124/psn-pdf
     February 18, 2011 - A high proportion of errors occurred at the prescribing stage, and therefore could have been prevented

222. 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

223. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39298/psn-pdf
     June 11, 2010 - reports submitted to this Web-based error reporting system revealed that most of the serious errors occurred

224. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37737/psn-pdf
     January 06, 2017 - All reported incidents were reviewed by physicians to determine if a true error occurred. 

225. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41887/psn-pdf
     January 07, 2015 - improved teamwork and safety climate, compared with procedures performed when changes in team members occurred

226. 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.

227. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44001/psn-pdf
     May 06, 2015 - This study found that wrong- site block occurred at a rate of about 1 per 10,000 nerve blocks, and these

228. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43715/psn-pdf
     November 26, 2014 - Despite the robust effort, there were no differences in post-discharge adverse events, which occurred

229. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37156/psn-pdf
     October 06, 2011 - Approximately one error occurred for every five patient-days, although more than three-quarters of these

230. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43087/psn-pdf
     April 02, 2014 - However, clinically significant errors still occurred in nearly half of all medication administrations

231. 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

232. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34839/psn-pdf
     April 06, 2011 - Problematic communication occurred in nearly one-third of all exchanges between team members, and appeared

233. 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

234. 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

235. The art of apology: when and how to seek forgiveness. | PSNet
     psnet.ahrq.gov/issue/art-apology-when-and-how-seek-forgiveness
     May 17, 2023 - This article offers practical advice on how to determine when an error has occurred and discusses the

236. VA pauses $16B Oracle Cerner EHR deployments indefinitely to address error-ridden early rollout. | PSNet
     psnet.ahrq.gov/issue/va-pauses-16b-oracle-cerner-ehr-deployments-indefinitely-address-error-ridden-early-rollout
     September 14, 2022 - Notable problems have occurred during the testing of the new electronic health records (EHR) system

237. RaDonda Vaught says some system practices contributed to fatal mistake. | PSNet
     psnet.ahrq.gov/issue/vaught-says-some-system-practices-contributed-fatal-mistake
     September 29, 2021 - summarizes a presentation by a nurse charged criminally after a medication mistake, her memory of what occurred

238. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/48130/psn-pdf
     August 07, 2019 - Investigators found that adverse events occurred after approximately half of discharges.

239. Total systems safety supports practitioners in partnering with families to protect patients. | PSNet
     psnet.ahrq.gov/issue/total-systems-safety-supports-practitioners-partnering-families-protect-patients
     April 17, 2024 - This article summarizes a case where problems were not responded to, and harm occurred.

240. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46877/psn-pdf
     March 14, 2018 - Information revealed by the data include impacts on length of stay, average costs, and whether the ADE occurred