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Total Results: over 10,000 records

Showing results for "occurred".

41. Identifying health information technology usability issues contributing to medication errors across medication process stages. | PSNet
    psnet.ahrq.gov/issue/identifying-health-information-technology-usability-issues-contributing-medication-errors
    November 03, 2021 - event reports to identify the type of medication error , the stage in the process in which the error occurred … Errors in dosing were the most frequent type, and occurred during ordering or reviewing.

42. Enteral nutrition: an underappreciated source of patient safety events. | PSNet
    psnet.ahrq.gov/issue/enteral-nutrition-underappreciated-source-patient-safety-events
    February 01, 2023 - reported events were classified as "care management events," eg, incorrect rate or dosage; 31% of errors occurred … during administration ; and 28% occurred during monitoring.

43. Critical incidents involving the medical emergency team: a 5-year retrospective assessment for healthcare improvement. | PSNet
    psnet.ahrq.gov/issue/critical-incidents-involving-medical-emergency-team-5-year-retrospective-assessment
    November 11, 2020 - This retrospective study analyzed critical incidents that occurred during MET responses over a five-year … They mainly occurred due to lack of compliance with protocols and lack of available supplies.

44. The patients' perspective: hematological cancer patients' experiences of adverse events as part of care. | PSNet
    psnet.ahrq.gov/issue/patients-perspective-hematological-cancer-patients-experiences-adverse-events-part-care
    December 01, 2019 - In this study of oncology patients, more than one quarter perceived an adverse event had occurred. … While most were informed soon after the event occurred and given an explanation, fewer than half were

45. Medication errors in the care transition of trauma patients | PSNet
    psnet.ahrq.gov/issue/medication-errors-care-transition-trauma-patients
    September 02, 2020 - This observational, descriptive, prospective study comprises an analysis of the medication errors that occurred … Results indicate that most medication errors occurred in the trauma unit and 64.2% of these types of

46. Simon SR et al. 2006 "Computerized prescribing alerts and group academic detailing to reduce the use of potentially inappropriate medications in older people." | Digital Healthcare Research
    digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/simon-sr-et-al-2006
    January 01, 2006 - INTERVENTION: The computerized age-specific alerts occurred at the time of prescribing a targeted potentially … The alerts were programmed to 'pop up' only when both of the following circumstances occurred: 1. … Approximately 14 (82%) alerts per clinician occurred while ordering these medications for patients younger … January to June 2004), [they received] approximately four alerts per clinician, all of which, by design, occurred

47. Final Progress Report: Evaluation of Risk by Active Surveillance in the Emergency Department (ERASED) (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/hall1-report.pdf
    January 01, 2024 - events were categorized into two taxonomies: (1) the segment of emergency care in which the event occurred … Patient visits were eligible for inclusion if (1) the visit occurred in the adult emergency department … An additional category, transitions, was added to account for periods when an event occurred during … The nonideal care events were categorized into the segment of care in which they occurred (Figure 1) … Significant time was spent distinguishing the true process from workarounds, which occurred between

48. Objective Outcomes Data Collection Tool | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/mvp/modules/vae/objective-outcome-tool.html
    January 01, 2017 - Total number of episodes of mechanical ventilation How many episodes of mechanical ventilation have occurred … Total number of deaths How many deaths have occurred in the patients who have been or were mechanically

49. NPSD Data Spotlight - Patient Safety and COVID-19: A Qualitative Analysis of Concerns During the Public Health Emergency (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-ptsafety-and-covid-19.pdf
    November 01, 2021 - There is no evidence in these reports that any other type of patient safety concern occurred. … In several instances, the exposure occurred because staff were not following PPE protocols, such as … In other cases, the exposure occurred with an asymptomatic individual, and was later identified when … Additional near misses occurred when the wrong blood product (e.g., fresh frozen plasma versus COVID … PSOs generally provided data elements for the location in the facility where the event occurred and

50. Electronic Communications Across Provider Settings | Digital Healthcare Research
    digital.ahrq.gov/ahrq-funded-projects/electronic-communications-across-provider-settings
    January 01, 2023 - Project planning occurred in two rural settings. … Planning also occurred among six rural community health centers throughout New Hampshire.

51. Comprehensive Diabetes Care: Blood Pressure Control (<140/90 mm Hg) (pdf file)
    integrationacademy.ahrq.gov/sites/default/files/2020-07/Comprehensive_Diabetes_Care_Blood_Pressure.pdf
    January 01, 2020 - Diagnosis may occur at any time in the member’s history, but must have occurred by the end of the measurement … Diagnosis may occur during the measurement year or the year prior to the measurement year, but must have occurred

52. Relationships between medications used in a mental health hospital and types of medication errors: a cross-sectional study over an 8-year period. | PSNet
    psnet.ahrq.gov/issue/relationships-between-medications-used-mental-health-hospital-and-types-medication-errors
    November 29, 2023 - This study used 8 years of medication records to identify when in the medication process the error occurred … Nearly one-third of errors were wrong dose and occurred in the prescribing stage.

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

54. Statistical Brief #147: Emergency Department Visits and Hospital Inpatient Stays for Seasonal and 2009 H1N1 Influenza, 2008-2009 (pdf file)
    hcup-us.ahrq.gov/reports/statbriefs/sb147.pdf
    March 01, 2012 - ■ ED visits for influenza occurred at a rate of 417.5 per 100,000 population in 2009 compared to … Hospitalizations for influenza occurred at a rate of 53.1 per 100,000 population in 2009 compared to … In 2008, peak activity occurred in February (79.9 ED visits per 100,000 population). … In 2009, peak activity occurred in October (125.2 ED visits per 100,000 population). … During the second wave of the 2009 H1N1 pandemic, which occurred in the 2009–2010 influenza season

55. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/37446/psn-pdf
    January 06, 2017 - Investigators discovered that inpatient warfarin- related errors occurred most frequently during transcription … /documentation and administration, while outpatient errors occurred most frequently during prescribing

56. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/vae/objective-outcome-tool.docx
    January 01, 2017 - Total number of episodes of mechanical ventilation How many episodes of mechanical ventilation have occurred … Total number of deaths How many deaths have occurred in the patients who have been or were mechanically

57. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/36200/psn-pdf
    February 15, 2011 - Prior research revealed that patients wanted the physicians to apologize for the error, explain how it occurred … Approximately half of respondents declined to explain how the error occurred or discuss specific plans

58. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/39402/psn-pdf
    August 08, 2010 - A fatal vincristine error that occurred in the United Kingdom was the subject of a detailed investigation … preventing-vincristine-administration-errors https://psnet.ahrq.gov/issue/external-inquiry-adverse-incident-occurred-queens-medical-centre-nottingham

59. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/41522/psn-pdf
    December 02, 2014 - resulted in patient harm in the outpatient setting, and this study found that more than 250 such errors occurred … Although pharmacists intercepted nearly half the errors, more than one-third occurred at the time of

60. Omission of high-alert medications: a hidden danger. | PSNet
    psnet.ahrq.gov/issue/omission-high-alert-medications-hidden-danger
    January 11, 2017 - The investigation found that more than half of errors occurred during the administration process, and … September 27, 2016 External Inquiry into the adverse incident that occurred at Queen's