Results

Total Results: 4,035 records

Showing results for "occurred".

3281. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865412/psn-pdf
      March 27, 2024 - In the second clinical encounter, it appeared that a psychotic exacerbation occurred, but again systemic

3282. 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

3283. 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…

3284. 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…

3285. 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, …

3286. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33559/psn-pdf
      December 15, 2024 - Medication Reconciliation December 15, 2024 Medication Reconciliation. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/medication-reconciliation PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice in the patient safet…

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/49771/psn-pdf
      July 01, 2016 - identified this and related problems prior to their being discovered in the context of patient injury, as occurred

3289. 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

3290. 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

3291. 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

3292. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/851870/psn-pdf
      July 31, 2023 - the entire patient safety team at the facility, and often the leadership team, know that an event occurred

3293. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/840174/psn-pdf
      August 28, 2024 - In these matters, the issue is not whether any medical error occurred, but that whether payment to the

3294. 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

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. 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.

3297. 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

3298. 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

3299. 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

3300. 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