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Showing results for "occurred".

  1. Special K with no license to kill: accidental ketamine overdose on induction of general anesthesia. | PSNet

    psnet.ahrq.gov/issue/special-k-no-license-kill-accidental-ketamine-overdose-induction-general-anesthesia
    March 17, 2021 - Commentary Special K with no license to kill: accidental ketamine overdose on induction of general anesthesia. Citation Text: Warner LL, Smischney N. Accidental Ketamine Overdose on Induction of General Anesthesia. Am J Case Rep. 2018;19:10-12. Copy Citation Format: Google …

  2. Back to basics: counting soft surgical goods. | PSNet

    psnet.ahrq.gov/issue/back-basics-counting-soft-surgical-goods
    March 17, 2021 - Commentary Back to basics: counting soft surgical goods. Citation Text: Spruce L. Back to Basics: Counting Soft Surgical Goods. AORN J. 2016;103(3):298-301; quiz 302-3. doi:10.1016/j.aorn.2015.12.021. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML End…

  3. Concept analysis: wrong-site surgery. | PSNet

    psnet.ahrq.gov/issue/concept-analysis-wrong-site-surgery
    June 11, 2014 - Review Concept analysis: wrong-site surgery. Citation Text: Watson DS. Concept analysis: wrong-site surgery. AORN J. 2015;101(6):650-6. doi:10.1016/j.aorn.2015.03.012. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedI…

  4. Disclosing errors that affect multiple patients. | PSNet

    psnet.ahrq.gov/issue/disclosing-errors-affect-multiple-patients
    April 19, 2017 - Commentary Disclosing errors that affect multiple patients. Citation Text: Chafe R, Levinson W, Sullivan T. Disclosing errors that affect multiple patients. CMAJ. 2009;180(11):1125-7. doi:10.1503/cmaj.081016. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote …

  5. Fatal error sparks debate over punitive measures.  | PSNet

    psnet.ahrq.gov/issue/fatal-error-sparks-debate-over-punitive-measures
    May 20, 2020 - Newspaper/Magazine Article Fatal error sparks debate over punitive measures.  Citation Text: Fatal error sparks debate over punitive measures.  Fernandez J. Drug Topics. May 7, 2007. Copy Citation Save Save to your library Print Download PDF …

  6. Planning an MR suite: what can be done to enhance safety? | PSNet

    psnet.ahrq.gov/issue/planning-mr-suite-what-can-be-done-enhance-safety
    September 12, 2016 - Commentary Planning an MR suite: what can be done to enhance safety? Citation Text: Gilk TB, Kanal E. Planning an MR suite: What can be done to enhance safety? J Magn Reson Imaging. 2015;42(3):566-71. doi:10.1002/jmri.24794. Copy Citation Format: DOI Google Scholar PubMed B…

  7. A Prototype Computerized Provider Order Entry System Reduced Medication Errors | Digital Healthcare Research

    digital.ahrq.gov/2018-year-review/research-spotlights/prototype-computerized-provider-order-entry-system-reduced
    January 01, 2018 - A Prototype Computerized Provider Order Entry System Reduced Medication Errors Key Finding and Impact A prototype CPOE was developed that allowed providers to record medication indications and showed them the drug of choice for that indication. Providers testing the prototype CPOE correctly placed medication …

  8. Behind Human Error, Second Edition. | PSNet

    psnet.ahrq.gov/issue/behind-human-error-second-edition
    April 13, 2018 - Book/Report Classic Behind Human Error, Second Edition. Citation Text: Behind Human Error, Second Edition. Woods DD, Dekker S, Cook R, Johannesen L. Boca Raton, FL: CRC Press; 2017. ISBN: 9781317175537. Copy Citation Save Save to your lib…

  9. Disclosure Policy and Form (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/pdf/epc-ki-tep-confidentiality-form-fillable.pdf
    August 01, 2020 - Disclosure Policy and Form Print Form EPC Key Informant and Technical Expert Agree…

  10. Organizational learning in hospitals: a realist review. | PSNet

    psnet.ahrq.gov/issue/organizational-learning-hospitals-realist-review
    June 19, 2019 - Review Organizational learning in hospitals: a realist review. Citation Text: Lyman B, Jacobs JD, Hammond EL, et al. Organizational learning in hospitals: A realist review. J Adv Nurs. 2019;75(11):2352-2377. doi:10.1111/jan.14091. Copy Citation Format: DOI Google Scholar Bi…

  11. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. | PSNet

    psnet.ahrq.gov/issue/national-trauma-care-system-integrating-military-and-civilian-trauma-systems-achieve-zero
    September 12, 2018 - Book/Report A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Citation Text: A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Nat…

  12. Profiles in patient safety: medication errors in the emergency department. | PSNet

    psnet.ahrq.gov/issue/profiles-patient-safety-medication-errors-emergency-department
    February 03, 2010 - Study Profiles in patient safety: medication errors in the emergency department. Citation Text: Croskerry P, Shapiro MJ, Campbell S, et al. Profiles in patient safety: medication errors in the emergency department. Acad Emerg Med. 2004;11(3):289-99. Copy Citation Format: G…

  13. The vanishing nonforensic autopsy. | PSNet

    psnet.ahrq.gov/issue/vanishing-nonforensic-autopsy
    February 09, 2011 - Commentary The vanishing nonforensic autopsy. Citation Text: Shojania KG, Burton EC. The vanishing nonforensic autopsy. N Engl J Med. 2008;358(9):873-5. doi:10.1056/NEJMp0707996. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote …

  14. To err is human, to apologize is hard. | PSNet

    psnet.ahrq.gov/issue/err-human-apologize-hard
    September 28, 2022 - Commentary To err is human, to apologize is hard. Citation Text: Krakower TM. To err Is human, to apologize is hard. JAMA. 2021;326(3):223-224. doi:10.1001/jama.2021.10840. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId…

  15. Retained Swabs Following Invasive Procedures: Themes Identified from a Review of NHS Serious Incident Reports. | PSNet

    psnet.ahrq.gov/issue/retained-swabs-following-invasive-procedures-themes-identified-review-nhs-serious-incident
    February 21, 2024 - Book/Report Retained Swabs Following Invasive Procedures: Themes Identified from a Review of NHS Serious Incident Reports. Citation Text: Retained Swabs Following Invasive Procedures: Themes Identified from a Review of NHS Serious Incident Reports. Dorset, UK: Health Services Safety Inve…

  16. Serious Reportable Events in Healthcare—2011 Update. | PSNet

    psnet.ahrq.gov/issue/serious-reportable-events-healthcare-2011-update
    March 23, 2012 - Book/Report Classic Serious Reportable Events in Healthcare—2011 Update. Citation Text: Serious Reportable Events in Healthcare—2011 Update. Washington DC: National Quality Forum; December 2011. Copy Citation Save Save to your library…

  17. Guideline implementation: prevention of retained surgical items. | PSNet

    psnet.ahrq.gov/issue/guideline-implementation-prevention-retained-surgical-items
    October 23, 2024 - Commentary Guideline implementation: prevention of retained surgical items. Citation Text: Fencl JL. Guideline Implementation: Prevention of Retained Surgical Items. AORN J. 2016;104(1):37-48. doi:10.1016/j.aorn.2016.05.005. Copy Citation Format: DOI Google Scholar PubMed B…

  18. Missed injuries in trauma patients: a literature review. | PSNet

    psnet.ahrq.gov/issue/missed-injuries-trauma-patients-literature-review
    April 01, 2009 - Review Missed injuries in trauma patients: a literature review. Citation Text: Pfeifer R, Pape H-C. Missed injuries in trauma patients: A literature review. Patient Saf Surg. 2008;2:20. doi:10.1186/1754-9493-2-20. Copy Citation Format: DOI Google Scholar PubMed BibTeX End…

  19. Emergency department crowding: the canary in the health care system. | PSNet

    psnet.ahrq.gov/issue/emergency-department-crowding-canary-health-care-system
    March 30, 2022 - Study Emergency department crowding: the canary in the health care system. Citation Text: doi:10.1056/CAT.21.0217. Copy Citation Format: DOI BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download Citation Save Save to your …

  20. Inpatient Notes: mistakes in the hospital—communicating, apologizing, and beyond. | PSNet

    psnet.ahrq.gov/issue/inpatient-notes-mistakes-hospital-communicating-apologizing-and-beyond
    September 04, 2024 - Commentary Inpatient Notes: mistakes in the hospital—communicating, apologizing, and beyond. Citation Text: Kachalia A. Web Exclusives. Annals for Hospitalists Inpatient Notes - Mistakes in the Hospital-Communicating, Apologizing, and Beyond. Ann Intern Med. 2016;165(12):HO2-HO3. doi:10.…
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