Results

Total Results: 1,110 records

Showing results for "occurrence".

1021. A Sweet Case of Hidden Hydrogen Ions | PSNet
      psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions
      November 30, 2023 - Several factors may have contributed to this occurrence including misinterpretation of her laboratory

1022. Misplaced Nasogastric Tube Resulting in Aspiration | PSNet
      psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
      August 01, 2009 - guidelines and readily available techniques for healthcare professionals to utilize to prevent its occurrence

1023. Nothing Called Small Surgery | PSNet
      psnet.ahrq.gov/web-mm/nothing-called-small-surgery
      February 01, 2023 - tourniquets. 32     Ultimately, however, systemic processes need to be implemented to prevent adverse event occurrence

1024. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49801/psn-pdf
      August 01, 2017 - A study of adverse occurrence and failure to rescue. Med Care. 1992;30:615-629.

1025. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72589/psn-pdf
      December 23, 2020 - Harvard-affiliated hospitals and practice groups, missed and delayed breast cancer malpractice claims are a regular occurrence

1026. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60856/psn-pdf
      August 26, 2020 - Anesthesiologists Physical Status 4 or 5), high- risk operations (e.g., carotid endarterectomy), or the occurrence

1027. Classics and Emerging Classics | PSNet
      psnet.ahrq.gov/classics
      August 01, 2023 - This analysis examined the occurrence of missed acute cardiac ischemia among over 10...

1028. Medication Mix-Up Leads to Patient Death | PSNet
      psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
      July 08, 2022 - Medication Mix-Up Leads to Patient Death Citation Text: Sanchez L, Romano PS. Medication Mix-Up Leads to Patient Death. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: Google Scholar BibTeX En…

1029. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865656/psn-pdf
      April 24, 2024 - Verbal Orders and Medication Overrides: A Dangerous Combination April 24, 2024 Mueller C, MacDowell P, Bourgeois JA. Verbal Orders and Medication Overrides: A Dangerous Combination. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination The Case A 26-ye…

1030. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/855057/psn-pdf
      October 31, 2023 - Addressing Workplace Violence and Creating a Safer Workplace October 31, 2023 Jones CB, Sousane Z, Mossburg S. Addressing Workplace Violence and Creating a Safer Workplace. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/addressing-workplace-violence-and-creating-safer-workplace While violence in the w…

1031. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/853773/psn-pdf
      September 27, 2023 - A Double “Never Event”: Wrong Patient and Wrong Side. September 27, 2023 Bellini A, Salcedo ES. A Double “Never Event”: Wrong Patient and Wrong Side. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side The Case A first-year orthopedic surgery resident was consulted…

1032. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/61078/psn-pdf
      October 28, 2020 - Inpatient Stroke Management in an Adolescent with Type 1 Diabetes and Home Insulin Pump October 28, 2020 Bagley B, Zuidema D, Crossen S, et al. Inpatient Stroke Management in an Adolescent with Type 1 Diabetes and Home Insulin Pump . PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/inpatient-stroke-management…

1033. Buprenorphine and the Medically Ill Patient | PSNet
      psnet.ahrq.gov/web-mm/buprenorphine-and-medically-ill-patient
      August 20, 2018 - Buprenorphine and the Medically Ill Patient Citation Text: McCance-Katz EF. Buprenorphine and the Medically Ill Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX E…

1034. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49573/psn-pdf
      January 01, 2009 - Dangerous Shift November 1, 2008 Patterson ES. Dangerous Shift. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/dangerous-shift Case Objectives Review the evidence base on erroneous actions related to shift changes. Understand the limits of standardizing handoffs in preventing errors at shift change. Expla…

1035. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33652/psn-pdf
      June 01, 2007 - Advancing Patient Safety Through State Reporting Systems June 1, 2007 Rosenthal J. Advancing Patient Safety Through State Reporting Systems. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/advancing-patient-safety-through-state-reporting-systems Perspective Seven years ago, the Institute of Medicine (I…

1036. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49584/psn-pdf
      April 01, 2009 - EMR Entry Error: Not So Benign April 1, 2009 Koppel R. EMR Entry Error: Not So Benign. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/emr-entry-error-not-so-benign The Case A 47-year-old man with advanced AIDS was admitted to an academic medical center with a chief complaint of shortness of breath. He was …

1037. Delirium or Dementia? | PSNet
      psnet.ahrq.gov/web-mm/delirium-or-dementia
      September 27, 2023 - Delirium in the intensive care unit: occurrence and clinical course in older patients.

1038. Cognitive Overload in the ICU | PSNet
      psnet.ahrq.gov/web-mm/cognitive-overload-icu
      June 01, 2005 - We know that characteristics of teamwork are intimately tied to the occurrence of errors and to their

1039. The Forgotten Turn | PSNet
      psnet.ahrq.gov/web-mm/forgotten-turn
      August 01, 2018 - provide an opportunity to analyze current systems that might need to be modified to prevent a similar occurrence

1040. Multifactorial Medication Mishap | PSNet
      psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
      September 01, 2016 - this error might discover failures that are amenable to higher leverage solutions to prevent future occurrence