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Showing results for "occurred".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36215/psn-pdf
    September 30, 2010 - oral-outpatient-chemotherapy-medication-errors-children-acute-lymphoblastic- leukemia This small cohort study demonstrated that dosing or administration errors occurred

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35047/psn-pdf
    November 04, 2015 - Although no clinical errors occurred, some records were misplaced.

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47176/psn-pdf
    June 06, 2018 - This news article reports on serious medication errors that occurred at Children's Hospital in 2017,

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/855098/psn-pdf
    November 08, 2023 - Falls requiring hospitalization more often occurred in residents’ bedrooms or communal areas.

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49624/psn-pdf
    May 01, 2011 - This case highlights two important issues, namely how to talk with a patient or family when the error occurred … cases, this case has numerous dimensions of uncertainty, making it difficult to know whether an error occurred … Therefore, in cases where a potential error occurred under other providers, the critical first step is … In addition, if it was determined that an error occurred, a collaborative approach to disclosure, in … If they determined that a clear error occurred, providers should have found a way to disclose the error

  6. Evaluation of Medications Removed from Automated Dispensing Machines Using the Override Function Leading to Multiple System Changes (pdf file)

    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Miller_93.pdf
    March 12, 2008 - The authors explained that these problems occurred when the pharmacy was closed and when all medications … Of the 59 instances of override, 17 (28.8 percent) occurred during a first shift (7:00 am to 3:30 pm … ); 31 (52.5 percent) occurred during a second shift (3:00 pm to 11:30 pm); and 11 (18.6 percent) occurred … Forty-five overrides (76.3 percent) occurred on weekdays. … The largest number of overrides occurred during the second shift, which was also when the majority of

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854378/psn-pdf
    October 11, 2023 - nurses, physicians, and other direct and indirect healthcare staff, 20% reported illegitimate tasks occurred

  8. Summary Skills Practice Exercise Sheet (pdf file)

    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module7/ts2-0ltc_module7_ig_summary_exsheet.pdf
    April 24, 2017 - Identify the instances where a breakdown in teamwork has occurred as it relates to the specific teamwork … SCENARIO: A gastrointestinal outbreak has occurred within the nursing home and has affected the entire

  9. Summary Skills Practice Exercise Sheet (pdf file)

    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module7/ts2-0ltc_module7_ig_summary_exsheet.pdf
    April 24, 2017 - Identify the instances where a breakdown in teamwork has occurred as it relates to the specific teamwork … SCENARIO: A gastrointestinal outbreak has occurred within the nursing home and has affected the entire

  10. Contact Site Administrators - COVID-19: Guidance to Action

    covid-acts.ahrq.gov/contactadministrators.action
    reporting an error please be sure you include information on what you were doing and the time the problem occurred

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37485/psn-pdf
    June 29, 2011 - The same respondents, compared to those without such an experience, believed that errors occurred more

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36982/psn-pdf
    June 11, 2017 - New Jersey Department of Health and Senior Services and that a list of these errors and where they occurred

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43304/psn-pdf
    July 02, 2014 - preventable patient safety events such as pressure ulcers and catheter-related bloodstream infections occurred

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37957/psn-pdf
    August 06, 2008 - surgical-management-and-outcomes-165-colonoscopic-perforations-single- institution Bowel perforation after colonoscopy occurred

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37095/psn-pdf
    September 04, 2010 - elective-neurosurgical- cases This analysis of cases performed by a single neurosurgeon found that errors occurred

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38705/psn-pdf
    June 17, 2009 - While events occurred mostly during unloading of the stretcher from the ambulance, injuries ranged from

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42560/psn-pdf
    September 18, 2013 - In this study, one alarm occurred every 2.9 minutes during the surgical procedures observed, implying

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42559/psn-pdf
    May 28, 2014 - analyze nursing students' perceptions of their responsibilities when a medication administration error occurred

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866167/psn-pdf
    June 19, 2024 - observational study of 298 pediatric nurses at one hospital in Sydney, Australia, found that errors occurred

  20. 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
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