-
psnet.ahrq.gov/node/43244/psn-pdf
June 18, 2014 - The majority of clinical deteriorations occurred within 48 hours of
admission, often while the patient
-
psnet.ahrq.gov/node/41952/psn-pdf
January 16, 2013 - After the system improvements were implemented, no similar errors
occurred and multiple near misses
-
psnet.ahrq.gov/node/50931/psn-pdf
February 26, 2020 - However, the rarity of this condition, especially if it involves a subacute presentation—as likely occurred … (nasogastric and pleural space), fluid
resuscitation, and early antibiotics, some or all of which occurred … This failure occurred despite several clues
suggesting gastrointestinal tract perforation and a prolonged
-
psnet.ahrq.gov/node/836774/psn-pdf
March 23, 2022 - Out-of-hours discharges often occurred
prematurely, without adequate handovers, and involved patients
-
psnet.ahrq.gov/node/852746/psn-pdf
August 23, 2023 - Diagnostic errors occurred most often in the testing, assessment, and follow-up phases, with
human factors
-
psnet.ahrq.gov/node/764396/psn-pdf
March 02, 2022 - a mobile health tool, pediatric patients and families were encouraged to report safety events that occurred
-
psnet.ahrq.gov/node/44915/psn-pdf
January 01, 2020 - Although research suggests that EHRs have had an overall positive effect, unexpected
consequences have occurred
-
psnet.ahrq.gov/node/47502/psn-pdf
June 02, 2019 - retrospective study of critical events in inpatient anesthesiology practice found
that debriefing occurred
-
psnet.ahrq.gov/node/850161/psn-pdf
June 07, 2023 - Overall, most incidents occurred at
the prescribing stage, but varied by patient age group.
-
digital.ahrq.gov/sites/default/files/docs/publication/uc1hs015400-brown-final-report-2008.pdf
January 01, 2008 - Process that reported medication errors occurred by facility
Admin
istering
Dis
pensing
Docu … Count of where in process the reported medication error occurred
Figure 2b. … Count of where in process the reported medication error occurred
0
33
67
100
C
ou
nt
60 … C o unt o f w here i n pro cess t he reported medication error occurred
0
33
67
100
C
ou … Count of where in process the reported medication error occurred
0
33
67
100
C
ou
nt
30
-
psnet.ahrq.gov/node/39303/psn-pdf
February 17, 2010 - Errors occurred in all three states of the test cycle.
-
psnet.ahrq.gov/node/44559/psn-pdf
April 15, 2016 - Researchers determined that diagnostic errors occurred in 35 of 100 reviewed cases, with the
majority
-
psnet.ahrq.gov/node/44015/psn-pdf
September 09, 2015 - safety-clinical-and-non-clinical-decision-makers-telephone-triage-narrative-
review
This narrative review of safety in telephone triage found that the lowest error rates occurred
-
psnet.ahrq.gov/node/42781/psn-pdf
December 04, 2013 - simulator-based study observed trauma teams and found that proven
techniques, such as closed-loop communication, occurred
-
psnet.ahrq.gov/node/41215/psn-pdf
September 04, 2013 - A case of an ultimately fatal adverse event that
occurred while a patient was being transported from
-
psnet.ahrq.gov/node/35175/psn-pdf
June 23, 2009 - overnight-and-postcall-errors-medication-orders
This study examined the incidence of prescribing errors that occurred
-
psnet.ahrq.gov/node/40745/psn-pdf
September 07, 2011 - However, direct verbal communication
occurred in only a small minority of cases, and several preventable
-
psnet.ahrq.gov/node/45941/psn-pdf
March 08, 2017 - Three major insulin administration errors occurred, which led to training
and process changes in order
-
psnet.ahrq.gov/node/44402/psn-pdf
January 22, 2016 - communication-amc-va-end-shift
This qualitative analysis found that anticipatory management conversation occurred
-
psnet.ahrq.gov/node/41210/psn-pdf
January 03, 2017 - case-study-safety-impact-implementing-smart-patient-controlled-analgesic-
pumps-tertiary-care
After adverse events occurred