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Showing results for "occurred".

  1. Learning From Defects Through Sensemaking: Facilitator Notes | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-fac-notes.html
    December 01, 2017 - So, first look at the system and analyze why the mistake occurred. … What actions occurred? What were the team members thinking and feeling? … Say: These are the types of questions to ask to understand how a defect occurred. … Try to find out exactly how things occurred in real time. Slide 14: What Happened? … No timeouts or debriefings occurred. Note: Spend 10 to 15 minutes discussing the case.

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41269/psn-pdf
    October 19, 2012 - characteristics-medication-errors-parenteral-cytotoxic-drugs This Swedish study found that chemotherapy medication errors occurred

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/864369/psn-pdf
    March 13, 2024 - A physician-related medication error occurred in 12.5% of participants overall, with no statistically

  4. Chapter 2. Fall Response | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man2.html
    December 01, 2017 - Unless there is evidence suggesting otherwise, the most logical conclusion is that a fall has occurred … distance to the next lower surface (in this case, the floor) is not a factor in determining whether a fall occurred … , an immediate intervention should be put in place by the nurse during the same shift that the fall occurred

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72479/psn-pdf
    November 18, 2020 - According to these findings, patient-perceived medical errors and harms occurred most commonly in women

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836987/psn-pdf
    April 27, 2022 - Transfer) events (i.e., cardiopulmonary arrest and/or ventilation and/or hemodynamic support) which occurred

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838136/psn-pdf
    September 21, 2022 - The majority of activations occurred in general medicine units and some patients (approximately 5%)

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851191/psn-pdf
    July 05, 2023 - disclosing-medical-errors-prioritising-needs-patients-and-families Numerous organizations promote communication with patients and families after harm has occurred

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72596/psn-pdf
    January 01, 2021 - This study of 254 intensive care patients across Western Europe found that serious adverse events occurred

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60662/psn-pdf
    January 01, 2022 - Incorrect doses and omitted medications occurred most frequently.

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848381/psn-pdf
    May 03, 2023 - 16b-oracle-cerner-ehr-deployments-indefinitely-address-error- ridden-early-rollout Notable problems have occurred

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837316/psn-pdf
    June 01, 2022 - Identified weaknesses included lack of discussions about misdiagnoses when they occurred.

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850173/psn-pdf
    June 07, 2023 - Transportation Safety Board concept, the proposed agency would collect data on facilities where errors occurred

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73530/psn-pdf
    July 28, 2021 - Most errors occurred during the prescribing stage and were the result of interrelated causes such as

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853066/psn-pdf
    August 30, 2023 - Researchers found that MOID occurred in 29% of emergency transfer cases and it was associated with higher

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45262/psn-pdf
    April 01, 2021 - involving parents in the analysis, engaging external experts to gain broader perspectives about what occurred

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50820/psn-pdf
    January 22, 2020 - communication, such as hanging up the phone) were noted by more than half of individuals surveyed and occurred

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42870/psn-pdf
    January 15, 2014 - efforts to drive safety improvement but notes that more than 280,000 preventable patient safety events occurred

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35778/psn-pdf
    July 20, 2010 - They found that AIP occurred most frequently after thoracentesis, but also during other procedures.

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35890/psn-pdf
    July 26, 2010 - issue/incidents-during-out-hospital-patient-transportation The authors analyzed adverse events that occurred
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