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Total Results: 4,038 records

Showing results for "occurred".

3281. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49708/psn-pdf
      May 01, 2014 - high-risk (based on age) and had medication reconciliation performed by a pharmacist, an error still occurred

3282. Medication Reconciliation: Whose Job Is It? | PSNet
      psnet.ahrq.gov/web-mm/medication-reconciliation-whose-job-it
      May 01, 2018 - determined that the gabapentin liquid had been refilled earlier than expected and that an overdose had occurred

3283. Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals? | PSNet
      psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
      March 01, 2004 - false-positive rate, it is still difficult to shake the intuition that unexpected deaths such as the one that occurred

3284. No News May Not Be Good News | PSNet
      psnet.ahrq.gov/web-mm/no-news-may-not-be-good-news
      December 07, 2009 - primary care practice was 3 days.( 9 ) Additionally, in 14% of cases of marked hyperkalemia, no follow-up occurred

3285. In Conversation with... Charles Ornstein | PSNet
      psnet.ahrq.gov/perspective/conversation-charles-ornstein
      October 01, 2009 - In Conversation with... Charles Ornstein October 1, 2009  Also Read an Essay Citation Text: In Conversation with.. Charles Ornstein . PSNet [internet]. 2009.In Conversation with... Charles Ornstein . PSNet [internet]. Rockville (MD): Agency for Healthcare Researc…

3286. The Media: An Essential, If Sometimes Arbitrary, Promoter of Patient Safety | PSNet
      psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety
      October 01, 2009 - The Media: An Essential, If Sometimes Arbitrary, Promoter of Patient Safety Robert M. Wachter, MD | October 1, 2009  Also Read a Conversation View more articles from the same authors. Citation Text: Wachter R. The Media: An Essential, If Sometimes Arbitrary, Pro…

3287. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60865/psn-pdf
      August 31, 2020 - Another experience that was of vital importance to me occurred just a couple of years ago when I met

3288. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33843/psn-pdf
      October 01, 2017 - One of the other changes that has occurred along with the shift work is now physicians are being held

3289. Algorithm-Based Decision Support System Guides Trauma Staff During Initial Treatment, Leading to Fewer Medical Errors | PSNet
      psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during-initial-treatment
      May 31, 2023 - finding that a quarter of trauma deaths in Victoria could have been prevented if medical errors had not occurred

3290. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49771/psn-pdf
      July 01, 2016 - identified this and related problems prior to their being discovered in the context of patient injury, as occurred

3291. Inpatient Stroke Management in an Adolescent with Type 1 Diabetes and Home Insulin Pump | PSNet
      psnet.ahrq.gov/web-mm/inpatient-stroke-management-adolescent-type-1-diabetes-and-home-insulin-pump
      February 01, 2023 - Additionally, insulin pump infusion site leakage occurred several times, possibly due to improper insertion

3292. Battle Buddy Pocket Card - Final (1) (pdf file)
      psnet.ahrq.gov/sites/default/files/2021-09/Battle%20Buddy%20Pocket%20Card%20-%20final%20(1).pdf
      January 01, 2021 - COVID 19 Battle Buddy Support Program Background: COVID-19 is a pandemic that threatens not only our patients but ourselves and our sense of safety and control. Like soldiers on a battlefield, our front line staff are coping with ongoing uncertainty about the scope of the threat, concerns about adequate PPE, …

3293. 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

3294. 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.

3295. 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

3296. 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

3297. 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

3298. 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

3299. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49593/psn-pdf
      October 01, 2009 - nasal cavity (so that its external portion was no longer extruding from the nose), but presumably this occurred … trachea and right bronchus.(1) One death was reported in a case with an aspirated airway, although this occurred … Nonetheless, some discussion regarding the NPA should have occurred prior to intubation, since the anesthesiologist

3300. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49863/psn-pdf
      May 01, 2019 - multiple units of blood, and fortunately the injury was repaired before more serious consequences occurred … to ensure safety issues are recognized, announced, and treated by the team in a timely fashion, as occurred … In this case, the first challenge occurred when the anesthesiologist alerted the surgeon during the