Results

Total Results: 4,231 records

Showing results for "occurred".

461. 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

462. 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

463. Medical errors leave devastating impact on families, professionals. | PSNet
     psnet.ahrq.gov/issue/medical-errors-leave-devastating-impact-families-professionals
     August 11, 2010 - May 3, 2006 External Inquiry into the adverse incident that occurred at Queen's Medical

464. Patient safety and acute care medicine: lessons for the future, insights from the past. | PSNet
     psnet.ahrq.gov/issue/patient-safety-and-acute-care-medicine-lessons-future-insights-past
     April 27, 2022 - February 3, 2016 External Inquiry into the adverse incident that occurred at Queen's

465. Updated guidance needed for longstanding large volume parenteral (LVP) labeling and packaging problems. | PSNet
     psnet.ahrq.gov/issue/updated-guidance-needed-longstanding-large-volume-parenteral-lvp-labeling-and-packaging
     March 10, 2021 - December 30, 2014 External Inquiry into the adverse incident that occurred at Queen's

466. Ockenden Report. Emerging Fndings and Recommendations from the Independent Review of Maternity Services at the Shrewsbury and Telford Hospital NHS Trust. | PSNet
     psnet.ahrq.gov/issue/ockenden-report-emerging-fndings-and-recommendations-independent-review-maternity-services
     April 27, 2022 - June 17, 2014 External Inquiry into the adverse incident that occurred at Queen's Medical

467. 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

468. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49427/psn-pdf
     January 01, 2004 - We know nothing of this surgeon's training, the time of day the injury occurred, or pertinent environmental … This procedure may have occurred in a hospital where an urologist was not immediately available, a situation … wrong-site surgery.(8,9) This patient had his testicle surgically removed, but similar disasters have occurred

469. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49616/psn-pdf
     December 01, 2010 - The second error in this case occurred when the nurse administered the entire contents of the 20-mg … While this error may have occurred because the printed instructions were not followed by the nurse, it … psnet.ahrq.gov//#references https://psnet.ahrq.gov//#references https://psnet.ahrq.gov//#references children occurred

470. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49782/psn-pdf
     January 01, 2017 - 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 … frame—of 138 published cases of local tissue injury where the duration of infusion was given, only 4 occurred

471. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/836812/psn-pdf
     March 30, 2022 - effective when conducted by a team of people from the process or area where the patient safety issue occurred … events are mitigated and prevented.3 Rather than simply reacting to adverse events after they have occurred

472. Root Cause Analysis | PSNet
     psnet.ahrq.gov/primer/root-cause-analysis
     March 30, 2022 - analyze the sequence of events leading to the error, with the goals of identifying how the event occurred … (through identification of active errors) and why the event occurred (through systematic identification

473. 2012 ISMP International Medication Safety Self Assessment for Oncology. | PSNet
     psnet.ahrq.gov/issue/2012-ismp-international-medication-safety-self-assessment-oncology
     January 26, 2023 - June 25, 2013 External Inquiry into the adverse incident that occurred at Queen's Medical

474. Commission of Inquiry on Hormone Receptor Testing. | PSNet
     psnet.ahrq.gov/issue/commission-inquiry-hormone-receptor-testing
     February 08, 2023 - May 21, 2014 External Inquiry into the adverse incident that occurred at Queen's Medical

475. IV Push Gap Analysis Tool (GAT) helps uncover national priorities for safe injection practices. | PSNet
     psnet.ahrq.gov/issue/iv-push-gap-analysis-tool-gat-helps-uncover-national-priorities-safe-injection-practices
     August 14, 2019 - June 21, 2015 External Inquiry into the adverse incident that occurred at Queen's Medical

476. Oral syringes: a crucial and economical risk-reduction strategy that has not been fully utilized. | PSNet
     psnet.ahrq.gov/issue/oral-syringes-crucial-and-economical-risk-reduction-strategy-has-not-been-fully-utilized
     June 10, 2018 - December 30, 2014 External Inquiry into the adverse incident that occurred at Queen's

477. National Patient Safety Syllabus 1.0 Training for all NHS Staff. | PSNet
     psnet.ahrq.gov/issue/national-patient-safety-syllabus-10-training-all-nhs-staff
     September 26, 2018 - October 31, 2016 External Inquiry into the adverse incident that occurred at Queen's

478. Fluorouracil Incident Root Cause Analysis Report. | PSNet
     psnet.ahrq.gov/issue/fluorouracil-incident-root-cause-analysis-report
     September 02, 2014 - May 11, 2014 External Inquiry into the adverse incident that occurred at Queen's Medical

479. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49752/psn-pdf
     January 01, 2016 - Long-lasting pain after acute irritation, as occurred in this case, appears to be relatively uncommon … time it is started, the protein denaturation and lipid alterations in the damaged tissue have already occurred

480. Failed check system for chemotherapy leads to pharmacist's "no contest" plea for involuntary manslaughter. | PSNet
     psnet.ahrq.gov/issue/failed-check-system-chemotherapy-leads-pharmacists-no-contest-plea-involuntary-manslaughter
     May 07, 2018 - May 2, 2018 External Inquiry into the adverse incident that occurred at Queen's Medical