Results

Total Results: 4,035 records

Showing results for "occurred".

3241. Improving patient safety by taking systems seriously. | PSNet
      psnet.ahrq.gov/issue/improving-patient-safety-taking-systems-seriously
      April 17, 2013 - December 9, 2014 External Inquiry into the adverse incident that occurred at Queen's

3242. What doctors can learn from the factory floor. | PSNet
      psnet.ahrq.gov/issue/what-doctors-can-learn-factory-floor
      June 13, 2011 - August 9, 2013 External Inquiry into the adverse incident that occurred at Queen's Medical

3243. Engineering Patient Safety in Radiation Oncology: University of North Carolina's Pursuit for High Reliability and Value Creation. | PSNet
      psnet.ahrq.gov/issue/engineering-patient-safety-radiation-oncology-university-north-carolinas-pursuit-high
      May 04, 2016 - October 23, 2013 External Inquiry into the adverse incident that occurred at Queen's

3244. Achieving Safe Health Care: Delivery of Safe Patient Care at Baylor Scott & White Health. | PSNet
      psnet.ahrq.gov/issue/achieving-safe-health-care-delivery-safe-patient-care-baylor-scott-white-health
      October 11, 2016 - October 14, 2015 External Inquiry into the adverse incident that occurred at Queen's

3245. Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-dimer. | PSNet
      psnet.ahrq.gov/web-mm/fatal-oversight-misdiagnosis-nocturnal-chest-pain-elevated-d-dimer
      May 01, 2005 - It is unclear if transitions of care occurred in this case, but patient volume and turnover demands often

3246. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33637/psn-pdf
      August 01, 2006 - But it really never occurred to me.

3247. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33622/psn-pdf
      November 01, 2005 - It occurred first at the level of the leadership groups that I asked to help.

3248. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/850675/psn-pdf
      June 14, 2023 - It is an opportunity to build on the family’s understanding of what occurred during the last shift and

3249. Death by PCA | PSNet
      psnet.ahrq.gov/web-mm/death-pca
      January 06, 2017 - Thus, confirmation bias ( 9 ) likely occurred with the post-anesthesia care unit (PACU) nurses.

3250. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49712/psn-pdf
      June 01, 2014 - provide counseling, but it is likely that an insufficient exchange of information and instruction occurred

3251. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49627/psn-pdf
      June 01, 2011 - Identity mixups still occurred, but probably somewhat less frequently than they do now, for in Times

3252. Microsoft PowerPoint - Spotlight Case_Delayed Diagnosis and Treatment of Lupus_SLIDES - FINAL.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2024-03/delayed_diagnosis_and_treatment_of_sle.pdf
      January 01, 2024 - • In the second clinical encounter, it appeared that a psychotic exacerbation occurred, but again

3253. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33842/psn-pdf
      January 01, 2018 - involves use of computer-based triggers, or indications stored in the database that an error might have occurred

3254. Patient Safety 2030. | PSNet
      psnet.ahrq.gov/issue/patient-safety-2030
      April 13, 2016 - February 26, 2014 External Inquiry into the adverse incident that occurred at Queen's

3255. A model of chemotherapy education for novice oncology nurses that supports a culture of safety. | PSNet
      psnet.ahrq.gov/issue/model-chemotherapy-education-novice-oncology-nurses-supports-culture-safety
      September 24, 2010 - November 30, 2016 External Inquiry into the adverse incident that occurred at Queen's

3256. Which Line: Ordering Provider or Proceduralist? | PSNet
      psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
      September 16, 2015 - inspection, the least effective approach, adverse events are captured after the error or issue has occurred … For this case, self-check would have occurred if the ordering physician had confirmed the order was for … Control means a system that captures when an error has occurred and blocks propagation, preventing patient … This type of successive check might well have identified the error before the adverse event occurred.

3257. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49681/psn-pdf
      April 01, 2013 - As occurred in this case, multiple failures across the PN-use process are usually identified in retrospect … Multiple warnings occurred daily with this patient's PN order, and ignoring them contributed to the error … One PN-related fatality occurred when an infant received a 1000-fold excess of zinc because of a mix-up … per day in another pediatric case was identified during PN infusion but before any adverse effect occurred

3258. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49419/psn-pdf
      October 01, 2003 - In the present case, as far as one can tell, no problems occurred in the routine biopsy, labeling, and … The wrong site surgery occurred because the surgeon remembered, incorrectly, that he had biopsied the … Patients who have not experienced errors report that, if a harmful error occurred in their treatment

3259. A Potent Medication Administered in a Not So Viable Route | PSNet
      psnet.ahrq.gov/web-mm/potent-medication-administered-not-so-viable-route
      July 20, 2016 - Of these, the majority occurred when vasopressors were given for a very long duration (55.9 ± 68.1 hours … The 2-hour limit was chosen because very few published cases of local tissue injury events occurred within … frame—of 138 published cases of local tissue injury where the duration of infusion was given, only 4 occurred

3260. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49451/psn-pdf
      June 01, 2004 - This particular event occurred on a Friday, as the physician left for the weekend. … follow-up on an important radiographic or laboratory test result) may reduce the risk of lapses such as occurred … That appears to have occurred here since laboratory staff called infection control staff, who called