Results

Total Results: 4,038 records

Showing results for "occurred".

261. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47096/psn-pdf
     November 14, 2018 - of the Veterans Health Administration root cause analysis database identified adverse events that occurred

262. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47426/psn-pdf
     October 13, 2018 - patient complaints submitted to England's National Health Service to identify stages of care where harm occurred

263. Coming Up Short: Maintaining Safety in the Face of Drug Shortages | PSNet
     psnet.ahrq.gov/web-mm/coming-short-maintaining-safety-face-drug-shortages
     November 01, 2012 - Further investigation revealed that this error had occurred on five other occasions, each committed by … The Institute for Safe Medication Practices (ISMP) reported in 2008 that at least 17 heparin errors occurred … young child in Ohio died due to an improperly compounded normal saline solution.( 6 ) The incident occurred

264. Another fatal failure at King/Drew. | PSNet
     psnet.ahrq.gov/issue/another-fatal-failure-kingdrew
     May 03, 2017 - This article reports on a death that occurred at the Martin Luther King Jr.

265. When a surgeon should just say 'I'm sorry'. | PSNet
     psnet.ahrq.gov/issue/when-surgeon-should-just-say-im-sorry
     February 05, 2014 - The program includes apology, disclosure, and explanation of what occurred as well as financial compensation

266. Medication errors: when pharmacy is closed. | PSNet
     psnet.ahrq.gov/issue/medication-errors-when-pharmacy-closed
     April 16, 2018 - This newsletter article discusses data on medication errors that occurred when pharmacy departments

267. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/61037/psn-pdf
     January 01, 2021 - Over half of the events were from outpatient subspecialty care; fewer events occurred in home/community

268. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44715/psn-pdf
     May 19, 2019 - Most cases occurred in ambulatory care settings, suggesting that current health IT may not be optimally

269. The safety of hospital stroke care. | PSNet
     psnet.ahrq.gov/issue/safety-hospital-stroke-care
     December 02, 2020 - researchers studied adverse events in stroke patients at one academic medical center and found that errors occurred

270. Managing patients with identical names in the same ward. | PSNet
     psnet.ahrq.gov/issue/managing-patients-identical-names-same-ward
     November 16, 2022 - Although no clinical errors occurred, some records were misplaced.

271. Eliciting the functional processes of apologizing for errors in health care: developing an explanatory model of apology. | PSNet
     psnet.ahrq.gov/issue/eliciting-functional-processes-apologizing-errors-health-care-developing-explanatory-model
     February 01, 2023 - and how such conversations can help restore the patient–physician relationship after an error has occurred

272. A national safety board made transportation safer and could do the same for health care, advocates say. | PSNet
     psnet.ahrq.gov/issue/national-safety-board-made-transportation-safer-and-could-do-same-health-care-advocates-say
     August 09, 2023 - Transportation Safety Board concept, the proposed agency would collect data on facilities where errors occurred

273. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35028/psn-pdf
     May 27, 2011 - Results include detailed description of the error types, the point at which the error occurred in the

274. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34670/psn-pdf
     January 01, 2006 - That is, when subjects were informed an outcome had occurred, it biased their hindsight view of events

275. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38414/psn-pdf
     March 31, 2009 - the National Patient Safety Agency found that most safety problems associated with airway devices occurred

276. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34893/psn-pdf
     February 26, 2009 - More than 800 ADEs occurred during the 9-month study period, with nearly 42% deemed preventable.

277. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44761/psn-pdf
     January 06, 2016 - colors for syringes) following the first event and made further revisions when the second incident occurred

278. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37648/psn-pdf
     January 12, 2012 - The majority of deaths and hospital transfers occurred in patients undergoing cosmetic procedures, incidents

279. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36797/psn-pdf
     August 26, 2011 - The surgeon-reviewers identify several problems in the categories of diagnosis and treatment that occurred

280. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44929/psn-pdf
     February 08, 2017 - Review of 1574 records from inpatient admissions revealed that adverse events occurred in approximately