Results

Total Results: 4,231 records

Showing results for "occurred".

441. Coming Up Short: Maintaining Safety in the Face of Drug Shortages | PSNet
     psnet.ahrq.gov/web-mm/coming-short-maintaining-safety-face-drug-shortages
     November 01, 2012 - Further investigation revealed that this error had occurred on five other occasions, each committed by … The Institute for Safe Medication Practices (ISMP) reported in 2008 that at least 17 heparin errors occurred … young child in Ohio died due to an improperly compounded normal saline solution.( 6 ) The incident occurred

442. 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

443. Sterile water should not be given "freely." | PSNet
     psnet.ahrq.gov/issue/sterile-water-should-not-be-given-freely
     March 18, 2010 - December 30, 2014 External Inquiry into the adverse incident that occurred at Queen's

444. Coding for Success: Simple Technology for Safer Patient Care. | PSNet
     psnet.ahrq.gov/issue/coding-success-simple-technology-safer-patient-care
     July 01, 2020 - April 27, 2022 External Inquiry into the adverse incident that occurred at Queen's Medical

445. Final Report of the Ockenden Review. | PSNet
     psnet.ahrq.gov/issue/final-report-ockenden-review
     January 13, 2021 - June 17, 2014 External Inquiry into the adverse incident that occurred at Queen's Medical

446. Periodic Issue | PSNet
     psnet.ahrq.gov/periodic-issue/periodic-issue-289
     April 28, 2021 - The most common diagnostic errors occurred in cardiovascular, infectious, congenital, and neurologic … This retrospective study analyzed critical incidents that occurred during MET responses over a five-year … They mainly occurred due to lack of compliance with protocols and lack of available supplies. … The most common diagnostic errors occurred in cardiovascular, infectious, congenital, and neurologic

447. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49855/psn-pdf
     March 01, 2019 - 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 … 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

448. 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

449. 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

450. HealthGrades Quality Study: Fourth Annual Patient Safety in American Hospitals Study. | PSNet
     psnet.ahrq.gov/issue/healthgrades-quality-study-fourth-annual-patient-safety-american-hospitals-study
     January 04, 2017 - nearly $9 billion in excess cost during 2003-2005, and nearly 250,000 potentially preventable deaths occurred

451. Medication error prevention by clinical pharmacists in two children's hospitals. | PSNet
     psnet.ahrq.gov/issue/medication-error-prevention-clinical-pharmacists-two-childrens-hospitals
     October 15, 2014 - Although error rates occurred most in inexperienced physicians, no group was error free.

452. Drug related admissions to a cardiology department; frequency and avoidability. | PSNet
     psnet.ahrq.gov/issue/drug-related-admissions-cardiology-department-frequency-and-avoidability
     August 20, 2018 - Admissions most frequently occurred in elderly patients and those on diuretics or digoxin.

453. HealthGrades Quality Study: Third Annual Patient Safety in American Hospitals Study. | PSNet
     psnet.ahrq.gov/issue/healthgrades-quality-study-third-annual-patient-safety-american-hospitals-study
     September 12, 2012 - than $9 billion in excess cost during 2002-2004, and more than 250,000 potentially preventable deaths occurred

454. The impact of abbreviations on patient safety. | PSNet
     psnet.ahrq.gov/issue/impact-abbreviations-patient-safety
     January 02, 2017 - dissemination of the Joint Commission's “do not use” abbreviation list, errors involving these abbreviations occurred

455. Periodic Issue | PSNet
     psnet.ahrq.gov/periodic-issue/periodic-issue-455
     September 25, 2024 - This analysis of 91 incident reports from care homes in England examined patient safety events that occurred … This study used 8 years of medication records to identify when in the medication process the error occurred … Nearly one-third of errors were wrong dose and occurred in the prescribing stage.

456. 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

457. 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

458. A Socio-cultural Perspective on Patient Safety. | PSNet
     psnet.ahrq.gov/issue/socio-cultural-perspective-patient-safety
     August 06, 2016 - January 15, 2014 External Inquiry into the adverse incident that occurred at Queen's

459. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39389/psn-pdf
     January 03, 2017 - shaping-systems-better-behavioral-choices-lessons-learned-fatal-medication- error This article discusses how a hospital responded to a fatal medication error that occurred

460. Contributions from Ergonomics and Human Factors. | PSNet
     psnet.ahrq.gov/issue/contributions-ergonomics-and-human-factors
     January 28, 2015 - July 3, 2013 External Inquiry into the adverse incident that occurred at Queen's Medical