Results

Total Results: 4,038 records

Showing results for "occurred".

361. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44302/psn-pdf
     August 04, 2015 - day-hospital-mortality- day-week The weekend effect of worse patient outcomes when admissions or procedures occurred

362. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44743/psn-pdf
     December 22, 2017 - nurses, patients, and caregivers about whether readmissions were preventable and why readmissions occurred

363. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41764/psn-pdf
     January 18, 2013 - after discharge increased by 22% if an adverse event (measured by the AHRQ Patient Safety Indicators) occurred

364. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44112/psn-pdf
     November 03, 2015 - This retrospective study used medical record review to uncover if medical error occurred in cases of

365. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37063/psn-pdf
     January 02, 2017 - significant barriers to reporting errors and did not report positive learning experiences when errors occurred

366. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41884/psn-pdf
     December 21, 2014 - Notably, these errors occurred at hospitals with computerized provider order entry systems, and the

367. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47173/psn-pdf
     June 06, 2018 - Most of the calls were classified as unintentional and occurred in patients who had been prescribed

368. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45608/psn-pdf
     October 27, 2016 - Investigators found that omission of vital sign recording occurred more than one third of the time.

369. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43299/psn-pdf
     December 23, 2016 - Most outbreaks occurred in hospitals, but a large number of cases also came from outpatient pain management

370. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41795/psn-pdf
     September 07, 2016 - Recently, a shortage of medicinal-grade ethanol occurred due to a temporary shutdown of the sole supplier

371. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35032/psn-pdf
     February 03, 2011 - They summarize the shifts in thinking that have occurred, from blaming individual physicians towards

372. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41974/psn-pdf
     February 01, 2013 - Although this study did not directly assess if errors occurred due to copying and pasting, an AHRQ WebM

373. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46302/psn-pdf
     December 22, 2017 - year study period, 67,603 unintentional medication errors that resulted in serious medical outcomes occurred

374. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40726/psn-pdf
     July 03, 2014 - record-using Many adverse event identification methods cannot detect errors until well after the event has occurred

375. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37254/psn-pdf
     January 02, 2017 - AHRQ WebM&M perspective written by two leaders at DFCI also discusses the organizational change that occurred

376. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35875/psn-pdf
     May 21, 2013 - universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person- surgery According to an AHRQ-supported study, wrong-site surgery occurred

377. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45562/psn-pdf
     October 12, 2016 - inconsistencies and gaps in information collected, including a lack of defined reasons explaining why incidents occurred

378. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36697/psn-pdf
     February 03, 2011 - The investigators found that direct communication occurred rarely, and the primary means of communication

379. Two Wrongs Don't Make a Right (Kidney) | PSNet
     psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney
     April 01, 2010 - The second error occurred during the patient transfer, when only the records, but not the imaging, accompanied … The third error occurred as the patient was posted for the surgical suite without preoperative imaging … These three errors occurred before the patient was rolled into the surgical suite. … The fourth error occurred once in the operating room—implementation of the Universal Protocol could have

380. A Conversation with Patient Safety Officers. | PSNet
     psnet.ahrq.gov/issue/conversation-patient-safety-officers
     April 30, 2024 - March 21, 2016 External Inquiry into the adverse incident that occurred at Queen's Medical