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Total Results: over 10,000 records

Showing results for "occurred".

181. 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

182. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60662/psn-pdf
     January 01, 2022 - Incorrect doses and omitted medications occurred most frequently.

183. 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%)

184. 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

185. 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

186. 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

187. 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

188. 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

189. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867519/psn-pdf
     January 15, 2025 - Around half of errors for each type of medication occurred at administration. 97% of errors resulted

190. 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

191. 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

192. Facilitator Guide: Learning From Defects Through Sensemaking (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects_facnotes.docx
     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 13 What Happened? … No timeouts or debriefings occurred. NOTE: Spend 10 to 15 minutes discussing the case.

193. Accessible Facilitator Guide: Learn From Defects for Sustainability (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_learn_from_defects_facnotes.docx
     December 01, 2017 - ASK: What if the same situation occurred on a different shift? … SAY: When a defect has already occurred, ask your frontline staff. … ASK: How do all these pieces lead to this error or the event that occurred? … If you can, simulate the defect, particularly for a defect that has occurred. … SAY: If a contributing factor is a major reason why the defect occurred, place that factor in the top

194. Sustainability: Learning From Defects: Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/surgery/modules/sustainability/learn-from-defects-fac-notes.html
     December 01, 2017 - Ask: What if the same situation occurred on a different shift? … Say: When a defect has already occurred, ask your frontline staff. … Ask: How do all these pieces lead to this error or the event that occurred? … If you can, simulate the defect, particularly for a defect that has occurred. … Say: If a contributing factor is a major reason why the defect occurred, place that factor in the top

195. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36996/psn-pdf
     September 24, 2016 - shadowed emergency department nurses and physicians and identified the types of interruptions that occurred

196. 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.

197. 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

198. 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

199. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39952/psn-pdf
     October 27, 2010 - Specimen labeling errors, most frequently involving labeling specimens with the wrong patient's name, occurred

200. An Overview of the CANDOR Process
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4/module4-event-reporting-investigation-analysis.pptx
     September 10, 2015 - information, other than event reports, that might provide information indicating that a CANDOR event has occurred … create a cohesive environment for informing the organization as to whether a CANDOR event may have occurred … implement the best practice of creating a hotline for staff to call when they feel a CANDOR event has occurred … Risk Management can also provide ongoing support to managers on the unit(s) where the event occurred. … Also, the location where the event occurred is generally no longer intact, so information that could