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Total Results: over 10,000 records

Showing results for "occurred".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/863747/psn-pdf
    March 06, 2024 - These near-miss events generally occurred in five clinical scenarios – high-risk social situations (

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73066/psn-pdf
    March 24, 2021 - The most common process failures contributing to patient harm occurred during order entry/transcription

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/61016/psn-pdf
    October 14, 2020 - Cardiac arrest and respiratory events occurred most frequently and largely affected very young children

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60556/psn-pdf
    June 03, 2020 - smart-pumps; post-implementation 27% of errors were attributed to the technology and would not have occurred

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73109/psn-pdf
    April 07, 2021 - This study analyzed 797 surgical never events that occurred from April 2012 to February 2020 in the

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836854/psn-pdf
    April 06, 2022 - Higher discrepancies occurred with respiratory and analgesic medications, underscoring the importance

  7. Hindsight Bias | PSNet

    psnet.ahrq.gov/glossary/hindsight-bias
    September 13, 2021 - the phrase "but for," as in "but for these errors in judgment, this terrible outcome would not have occurred

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867392/psn-pdf
    December 18, 2024 - AI detected five errors (compared with one error pre- implementation), four of which occurred when the

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36027/psn-pdf
    March 28, 2011 - medical-injuries-among-hospitalized-children This AHRQ–funded study applied new screening criteria to capture health care injuries that occurred

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37224/psn-pdf
    December 15, 2011 - Unintentional medication errors, including taking the prescribed medication at the wrong dose or time, occurred

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46648/psn-pdf
    March 14, 2018 - The majority of errors occurred during the compounding or dispensing and administration stages.

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43813/psn-pdf
    January 20, 2015 - An adverse event was present in 12% of return visits that occurred within 72 hours of the initial visit

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41000/psn-pdf
    December 14, 2011 - study found that the medication errors identified by an emergency department pharmacist primarily occurred

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34668/psn-pdf
    June 06, 2018 - from the Institute for Safe Medication Practices informing readers of a fatal medication error that occurred

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46366/psn-pdf
    September 27, 2017 - medical records of patients diagnosed with spinal epidural abscess and found that a delay in diagnosis occurred

  16. Right? Left? Neither! | PSNet

    psnet.ahrq.gov/web-mm/right-left-neither
    November 16, 2022 - The first error (or series of errors) occurred 2 weeks prior to admission when the staff in the ED who … The next group of errors occurred when the patient was admitted. … The final set of errors occurred prior to the patient receiving spinal anesthesia. … as cardiac arrest and neurological complications.( 9 ) The institution at which this adverse event occurred … process of identifying and labeling radiographs should be reviewed to discover exactly how the errors occurred

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46444/psn-pdf
    December 19, 2017 - This case discussion reviews an incident that occurred due to an NPO status order for a patient prior

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40530/psn-pdf
    September 25, 2011 - patient-safety-factors-children-dying-paediatric-intensive-care-unit-picu-case- notes-review This study found that adverse events occurred

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38804/psn-pdf
    July 22, 2009 - Most of the dosing errors occurred at home and in children younger than 12 months.

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38177/psn-pdf
    March 02, 2011 - This study adds to those concerns by finding that failures in behavioral practice occurred in nearly
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psnet.ahrq.gov (4038)

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