Results

Total Results: 4,231 records

Showing results for "occurred".

281. 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

282. Right? Left? Neither! | PSNet
     psnet.ahrq.gov/web-mm/right-left-neither
     November 16, 2022 - The first error (or series of errors) occurred 2 weeks prior to admission when the staff in the ED who … The next group of errors occurred when the patient was admitted. … The final set of errors occurred prior to the patient receiving spinal anesthesia. … as cardiac arrest and neurological complications.( 9 ) The institution at which this adverse event occurred … process of identifying and labeling radiographs should be reviewed to discover exactly how the errors occurred

283. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46587/psn-pdf
     January 23, 2019 - Workarounds occurred in about two-thirds of medication administrations.

284. 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.

285. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46774/psn-pdf
     April 12, 2019 - The number of surgeries in which a handoff occurred increased over time during the 6-year study period

286. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50931/psn-pdf
     February 26, 2020 - However, the rarity of this condition, especially if it involves a subacute presentation—as likely occurred … (nasogastric and pleural space), fluid resuscitation, and early antibiotics, some or all of which occurred … This failure occurred despite several clues suggesting gastrointestinal tract perforation and a prolonged

287. 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

288. 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

289. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47372/psn-pdf
     January 01, 2019 - frequently cited problem was missing test results, with about 15% of offices in the study citing that it occurred

290. 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

291. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47117/psn-pdf
     November 16, 2018 - Researchers used an all-cause harm trigger tool to assess what proportion of harms that occurred at

292. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35050/psn-pdf
     May 27, 2011 - The majority of errors that resulted in an ADE occurred in the medication ordering phase.

293. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36409/psn-pdf
     September 28, 2016 - Using a high-paced emergency department (ED) setting, investigators discovered that interruptions occurred

294. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38515/psn-pdf
     March 03, 2011 - Most errors occurred during drug administration. 

295. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34795/psn-pdf
     December 23, 2008 - The authors also present data on the stage at which an ADE occurred, consequences of the preventable

296. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46134/psn-pdf
     September 24, 2017 - Many of these errors occurred during the transition home after hospital discharge.

297. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36784/psn-pdf
     February 24, 2011 - many-faces-error-disclosure-common-set-elements-and-definition When medical errors occur, patients desire full disclosure about the error and why it occurred

298. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42933/psn-pdf
     July 03, 2014 - critical-events-during-land-based-interfacility-transport In this retrospective cohort study, critical events occurred

299. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34698/psn-pdf
     January 04, 2017 - process can fail, prioritize those failure modes, and take corrective action before failures have occurred

300. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38758/psn-pdf
     July 08, 2009 - overall incidence of errors appears low, most reported errors were considered preventable, as they occurred