Results

Total Results: 4,231 records

Showing results for "occurred".

321. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39512/psn-pdf
     June 11, 2010 - An AHRQ WebM&M commentary discusses a near miss that occurred due to a misidentification error in the

322. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47153/psn-pdf
     October 12, 2018 - The authors determined where process errors occurred, reviewed what factors were involved, and discussed

323. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34656/psn-pdf
     May 27, 2011 - Based on the pooled data, an estimated 1.7 errors per patient-day occurred, with nearly 2 severe or

324. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41925/psn-pdf
     November 26, 2014 - Both provider errors and patient misunderstanding occurred more frequently for medications prescribed

325. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37992/psn-pdf
     August 20, 2008 - Most reported errors occurred at the prescribing stage (e.g., prescribing an incorrect dose), and nearly

326. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41301/psn-pdf
     April 18, 2012 - Most errors occurred at the preanalytic phase (before the specimen arrived in the laboratory), with

327. 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

328. 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

329. 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.

330. 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

331. 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

332. 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

333. 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

334. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40636/psn-pdf
     November 21, 2011 - As in the earlier report, half of the incorrect procedures occurred outside of the operating room.

335. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36334/psn-pdf
     October 26, 2010 - As in the outpatient arena, errors generally occurred due to failure to order diagnostic tests or interpret

336. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35855/psn-pdf
     October 25, 2013 - than $9 billion in excess cost during 2002-2004, and more than 250,000 potentially preventable deaths occurred

337. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39123/psn-pdf
     April 30, 2014 - Errors occurred in virtually all specialties that perform procedures.

338. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41192/psn-pdf
     November 26, 2014 - This study found that reconciliation errors occurred frequently at both these transition times; 42%

339. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39193/psn-pdf
     April 21, 2011 - of errors, only 15% of radiologists said they would discuss the specifics of the error and how it occurred

340. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34689/psn-pdf
     February 10, 2011 - The authors break down ADEs by drug class and by the stage at which the error occurred (ordering, transcription