Results

Total Results: 4,038 records

Showing results for "occurred".

461. 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

462. 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

463. 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

464. 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

465. 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

466. 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

467. Commission of Inquiry on Hormone Receptor Testing. | PSNet
     psnet.ahrq.gov/issue/commission-inquiry-hormone-receptor-testing
     May 26, 2021 - May 21, 2014 External Inquiry into the adverse incident that occurred at Queen's Medical

468. 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

469. 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

470. 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

471. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33728/psn-pdf
     May 01, 2012 - might be tracked routinely as part of the patient's care that might indicate that an adverse event had occurred … triggers, as we had been through most of our IHI work, it was obviously detecting them after they had occurred … The adverse events that occurred in those three settings were of a range of severity. … It's easy to make the case that dramatic improvements in safety have occurred when that may not be in … The cascading of events that occurred in the Medicare study—more than a quarter of the patients had

472. 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

473. 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

474. 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

475. Missing ECG and Missed Diagnosis Lead to Dangerous Delay | PSNet
     psnet.ahrq.gov/web-mm/missing-ecg-and-missed-diagnosis-lead-dangerous-delay
     March 01, 2015 - results were notable for an elevated troponin level, suggesting that significant myocardial damage had occurred … 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

476. Inadvertent Castration | PSNet
     psnet.ahrq.gov/web-mm/inadvertent-castration
     October 27, 2010 - 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

477. Milliliters vs. Milligrams | PSNet
     psnet.ahrq.gov/web-mm/milliliters-vs-milligrams
     September 01, 2004 - The second error in this case occurred when the nurse administered the entire contents of the 20-mg multidose … While this error may have occurred because the printed instructions were not followed by the nurse, it … Bates, and colleagues reported that the most common errors in the medication use process in children occurred

478. ISMP's List of Confused Drug Names. | PSNet
     psnet.ahrq.gov/issue/ismps-list-confused-drug-names
     August 21, 2015 - November 6, 2013 External Inquiry into the adverse incident that occurred at Queen's

479. Diagnosis: Interpreting the Shadows. | PSNet
     psnet.ahrq.gov/issue/diagnosis-interpreting-shadows
     June 29, 2016 - July 15, 2013 External Inquiry into the adverse incident that occurred at Queen's Medical

480. Misadventures in Health Care: Inside Stories. | PSNet
     psnet.ahrq.gov/issue/misadventures-health-care-inside-stories
     July 06, 2011 - January 6, 2015 External Inquiry into the adverse incident that occurred at Queen's Medical