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Showing results for "occurred".

5601. 2021 National Healthcare Quality and Disparities Report: Executive Summary (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2021qdr-final-es.pdf
      January 01, 2021 - The decrease in suicide deaths occurred in White populations only, while death rates in Black populations

5602. Patient and Family Centered I-PASS (Family-Centered Communication Program to Reduce Medical Errors and Improve Family Experience and Communication Processes) | PSNet
      psnet.ahrq.gov/innovation/patient-and-family-centered-i-pass-family-centered-communication-program-reduce-medical
      February 26, 2025 - ways not apparent in the normal determination of adverse events. 4 The reduction in harmful events occurred

5603. It's Sarah, Not Stephen! | PSNet
      psnet.ahrq.gov/web-mm/its-sarah-not-stephen
      January 01, 2015 - The clinician acknowledged the error when it occurred, apologized for the harm done, and reassured both

5604. Root Cause Analysis Gone Wrong | PSNet
      psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
      August 28, 2024 - with industries such as aviation, those conducting RCA generally work in the place where the incident occurred

5605. When the Indications for Drug Administration Blur | PSNet
      psnet.ahrq.gov/web-mm/when-indications-drug-administration-blur
      May 26, 2021 - When the morning shift change occurred, the morning nurse evaluated the patient and found her to be barely

5606. Use of Push and Pull Health Information Exchange Technologies by Ambulatory Care Practices and the Impact on Potentially Avoidable Health Care Utilization - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/r01hs024556-vest-final-report-2019.pdf
      January 01, 2019 - Principal Findings Usage of “pull” HIE occurred in 3.1% of encounters and “push” HIE in 23.5% of encounters

5607. The Unfamiliar Catheter | PSNet
      psnet.ahrq.gov/web-mm/unfamiliar-catheter
      November 01, 2006 - connectors allow fluid to be pushed out to the catheter lumen to overcome the reflux of blood that has occurred

5608. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2021-04/final_psnet_spotlight_retained_vaginal_packing_04.08.2021.pdf
      January 01, 2021 - collaboration among clinicians — One study found that nurses prevented 86% of medical errors before they occurred

5609. Delayed Recognition of a Positive Blood Culture | PSNet
      psnet.ahrq.gov/web-mm/delayed-recognition-positive-blood-culture
      January 29, 2020 - While these efforts resulted in a 16% increase in documented follow-up, follow-up still only occurred

5610. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/861880/psn-pdf
      January 31, 2024 - ways not apparent in the normal determination of adverse events.4 The reduction in harmful events occurred

5611. Inadequate Preanesthetic Evaluation, Airway Trouble | PSNet
      psnet.ahrq.gov/web-mm/inadequate-preanesthetic-evaluation-airway-trouble
      November 01, 2023 - 2006, 6.6/1000 intubation attempts were described as difficult, and 0.2 failure to intubate scenarios occurred

5612. July Syndrome | PSNet
      psnet.ahrq.gov/web-mm/july-syndrome
      July 01, 2011 - Young, MD, MPP This patient's postoperative care occurred during the annual tsunami that disrupts

5613. Techno Trip | PSNet
      psnet.ahrq.gov/web-mm/techno-trip
      May 01, 2005 - Instead, the failure occurred because the IT design was technology-centered rather than human-centered

5614. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/61078/psn-pdf
      October 28, 2020 - Additionally, insulin pump infusion site leakage occurred several times, possibly due to improper insertion

5615. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49550/psn-pdf
      December 01, 2007 - false-positive rate, it is still difficult to shake the intuition that unexpected deaths such as the one that occurred

5616. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49543/psn-pdf
      September 01, 2007 - determined that the gabapentin liquid had been refilled earlier than expected and that an overdose had occurred

5617. D_ITPrivacyandSecurityPrimer (pdf file)
      digital.ahrq.gov/sites/default/files/docs/page/D_ITPrivacyandSecurityPrimer_1.pdf
      March 20, 1997 - disclosure of PHI and that audit log is not reviewed, it can later be claimed in a civil suit that damages occurred

5618. D_ITPrivacyandSecurityPrimer (pdf file)
      digital.ahrq.gov/sites/default/files/docs/page/D_ITPrivacyandSecurityPrimer_0.pdf
      March 20, 1997 - disclosure of PHI and that audit log is not reviewed, it can later be claimed in a civil suit that damages occurred

5619. Long Term Care e-Prescribing Standards Pilot Study - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/page/Long%20Term%20Care%20e-Prescribing%20Standards%20Pilot%20Study%20-%20Final%20Report_0.pdf
      October 25, 2025 - Achieve tracked the number and types of transmission errors for the NEWRX and CANRX NCPCP SCRIPTS that occurred … problems at the pharmacy when they are changed or discontinued. 3.6.4 Retention rates - No change occurred … DERF is available, the pharmacy system should review each NEWRX to see if any resident changes have occurred … Achieve tracked the number and types of transmission errors for the NEWRX and CANRX NCPCP SCRIPTS that occurred … The table below outlines these SCRIPT errors that occurred during the pilot.

5620. Network of Patient Safety Databases Chartbook, 2021 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2021.pdf
      January 01, 2021 - Note that this is neither the date the patient safety concern occurred nor the date the concern was … and provides the following possible responses: No harm, Unknown harm, or, if harm is known to have occurred … Incidents involving preparation or administration of Blood or Blood Products were reported to have occurred … However, the largest number of total harm events (n = 14; 28.0%) occurred during Product test or request … Numerous falls (17,326 /139,170; 12.4%) were reported to have occurred in Other location and Other area