Results

Total Results: 4,038 records

Showing results for "occurred".

421. Frequency, types, and potential clinical significance of medication-dispensing errors. | PSNet
     psnet.ahrq.gov/issue/frequency-types-and-potential-clinical-significance-medication-dispensing-errors
     February 03, 2011 - Errors occurred in approximately 1 of 40 doses dispensed by a unit-dose medication dispensing system.

422. A case study on the safety impact of implementing smart patient-controlled analgesic pumps at a tertiary care academic medical center. | PSNet
     psnet.ahrq.gov/issue/case-study-safety-impact-implementing-smart-patient-controlled-analgesic-pumps-tertiary-care
     August 31, 2016 - After adverse events occurred due to incorrect dosing of patient-controlled analgesia, implementation

423. Intra-operative monitoring—many alarms with minor impact. | PSNet
     psnet.ahrq.gov/issue/intra-operative-monitoring-many-alarms-minor-impact
     June 18, 2014 - In this study, one alarm occurred every 2.9 minutes during the surgical procedures observed, implying

424. Barriers to adverse event and error reporting in anesthesia. | PSNet
     psnet.ahrq.gov/issue/barriers-adverse-event-and-error-reporting-anesthesia
     April 19, 2017 - specified events, the influence of perceived barriers was dependent on whether an error actually occurred

425. Characteristics of medication errors with parenteral cytotoxic drugs. | PSNet
     psnet.ahrq.gov/issue/characteristics-medication-errors-parenteral-cytotoxic-drugs
     July 01, 2017 - This Swedish study found that chemotherapy medication errors occurred most frequently at the prescribing

426. Adverse Drug Events in U.S. Hospitals, 2010 Versus 2014. | PSNet
     psnet.ahrq.gov/issue/adverse-drug-events-us-hospitals-2010-versus-2014
     October 03, 2018 - Information revealed by the data include impacts on length of stay, average costs, and whether the ADE occurred

427. Please don't sleep through this wake-up call. | PSNet
     psnet.ahrq.gov/issue/please-dont-sleep-through-wake-call
     May 07, 2018 - from the Institute for Safe Medication Practices informing readers of a fatal medication error that occurred

428. Multiple Levels Involved in Prescribing the Wrong Medication | PSNet
     psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication
     December 23, 2020 - Although no major complications occurred in this case, it is an example of how mistakes are made, despite … Model  of accident causation is useful in understanding the multiple breakdowns in patient safety that occurred … SLICE 1: The Nurse Pending the Wrong Medication   The first failure in this case occurred when the nurse … The provider approving topiramate rather than trimethobenzamide is an individual level error, which occurred … In analyzing how this error occurred, there were three missed opportunities for intervention: 1) critical

429. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60977/psn-pdf
     January 08, 2020 - Although no major complications occurred in this case, it is an example of how mistakes are made, despite … Model of accident causation is useful in understanding the multiple breakdowns in patient safety that occurred … SLICE 1: The Nurse Pending the Wrong Medication  The first failure in this case occurred when the nurse … The provider approving topiramate rather than trimethobenzamide is an individual level error, which occurred … In analyzing how this error occurred, there were three missed opportunities for intervention: 1) critical

430. Eliminating vincristine administration events. | PSNet
     psnet.ahrq.gov/issue/eliminating-vincristine-administration-events
     February 15, 2023 - June 17, 2014 External Inquiry into the adverse incident that occurred at Queen's Medical

431. Patient Safety 101 | PSNet
     psnet.ahrq.gov/patient-safety-101
     March 26, 2025 - variety of established and emerging methods to prospectively identify safety hazards before errors have occurred

432. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49845/psn-pdf
     October 01, 2018 - Further investigation revealed that this error had occurred on five other occasions, each committed … The Institute for Safe Medication Practices (ISMP) reported in 2008 that at least 17 heparin errors occurred … a young child in Ohio died due to an improperly compounded normal saline solution.(6) The incident occurred

433. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49824/psn-pdf
     March 01, 2018 - results were notable for an elevated troponin level, suggesting that significant myocardial damage had occurred … the artery in under 90 minutes.(5) In the case described above, a critical communication breakdown occurred … regarding the results of the initial ECG tracing and the failure of transmission of the initial tracing occurred

434. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73999/psn-pdf
     October 27, 2021 - about 4% of claims against anesthesia providers are due to medication errors.6 Most of these errors occurred … when the wrong dose (31%) or wrong drug (24%) was administered.6 In this case, the error occurred when … the desired concentration of 50 mcg/ml, but this product was not available on the day when the error occurred

435. Not what the doctor ordered. | PSNet
     psnet.ahrq.gov/issue/not-what-doctor-ordered
     November 23, 2016 - May 3, 2006 External Inquiry into the adverse incident that occurred at Queen's Medical

436. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45113/psn-pdf
     May 11, 2016 - experienced clinical reviewers achieve only moderate interrater agreement on whether an adverse event occurred

437. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46990/psn-pdf
     July 25, 2018 - A WebM&M commentary discussed an adverse event that occurred due to a transcription error in a radiology

438. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40707/psn-pdf
     March 11, 2013 - This study conducted in-depth interviews with patients who believed an error occurred in their cancer-related

439. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45293/psn-pdf
     February 01, 2017 - analysis, researchers sought to identify the most common and serious event types, reasons these events occurred

440. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42868/psn-pdf
     October 31, 2014 - information to the patient and family and avoiding admissions of fault—or even admission that an error occurred