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psnet.ahrq.gov/web-mm/nonsustained-ventricular-tachycardia-after-acute-coronary-syndromes-recognizing-high-risk
September 20, 2011 - left ventricular ejection fraction • Heart failure (Killip II-IV) • Prior ventricular arrhythmia • Occurrence
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psnet.ahrq.gov/web-mm/mixup-beyond-medication-label
June 01, 2014 - should have been a red flag that prompted his providers to perform an in-depth review after the first occurrence
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psnet.ahrq.gov/web-mm/central-not-epidural
August 28, 2024 - Tubing misconnections—a persistent and potentially deadly occurrence. Sentinel Event Alert.
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psnet.ahrq.gov/node/49704/psn-pdf
March 01, 2014 - late-anemia-following-rh-disease-newborn
About 80% of normal term newborns become jaundiced.(1,2) Most of the time this is a benign occurrence
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psnet.ahrq.gov/node/49724/psn-pdf
January 01, 2015 - A study of adverse occurrence and failure to rescue. Med Care. 1992;30:615-629. [go
to PubMed]
6.
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/MWRHULpw6y_5Uk_KXTyvp8
January 10, 2017 - Does the effect of folic acid supplementation on NTDs (first occurrence) differ by race or ethnicity? … To what extent does folic acid supplementation re-
duce the risk for NTDs (first occurrence) in women … Does the effect of folic acid supplementation on
NTDs (first occurrence) differ by race or ethnicity? … Prevention of the first
occurrence of neural-tube defects by
periconceptional vitamin supplementation … Periconceptional vitamin use, dietary
folate, and the occurrence of neural tube defects.
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www.ahrq.gov/sites/default/files/2024-01/cohen-report.pdf
January 01, 2024 - the generic fault tree as a template
• Identify specific error pathways with a high probability of occurrence … Rates
Input from the modeling team was used to estimate the probability of failure or frequency of occurrence … trees, fault tree software94 calculated combinations of failures and the total
combined probability of occurrence … with this PADE was a rushed or inattentive data entry verification
process, with an estimated rate of occurrence
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Kizer1.pdf
April 01, 2004 - events are a leading cause
of death and injury, even though well-documented methods to prevent the
occurrence … Implement standardized protocols to prevent the occurrence of wrong-site procedures or
wrong-patient
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Lapane.pdf
March 09, 2005 - Further evaluation via the Resident Assessment Protocols
(RAPs) is “triggered” by the co-occurrence … process
developed for updating the drugs in GRAM includes review of quantitative data
on side effect occurrence
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Riley_59.pdf
April 06, 2008 - The key questions
asked of each Problem Statement are:
• What is the frequency of occurrence? … These include:
• What is the frequency of occurrence?
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/B8omJCgNDKfJLVXCz6nFw-
May 01, 2009 - Prevention of the first occurrence of neural-tube defects
by periconceptional vitamin supplementation … Periconceptional
vitamin use, dietary folate, and the occurrence of neural tube defects.
-
www.ahrq.gov/research/findings/final-reports/stpra/stpraapa2.html
April 01, 2018 - Aims
To discover any associations between preoperative variables and the occurrence of wound complications … Occurrence of infection was strongly associated with use of long-acting intraarticular intraoperative
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hcup-us.ahrq.gov/reports/statbriefs/sb167.jsp
November 01, 2013 - "All-listed" refers to the occurrence of one or more of these codes in any diagnosis field, and "first-listed … " refers to the occurrence of one or more of these codes in the first diagnosis field.
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psnet.ahrq.gov/node/47044/psn-pdf
April 18, 2018 - Bedside computer vision—moving artificial intelligence
from driver assistance to patient safety.
April 18, 2018
Yeung S, Downing L, Fei-Fei L, et al. Bedside Computer Vision - Moving Artificial Intelligence from Driver
Assistance to Patient Safety. New Engl J Med. 2018;378(14):1271-1273. doi:10.1056/NEJMp1716891.
…
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psnet.ahrq.gov/node/44746/psn-pdf
January 20, 2016 - Creating a culture of safety around bar-code medication
administration: an evidence-based evaluation framework.
January 20, 2016
Kelly K, Harrington L, Matos P, et al. Creating a Culture of Safety Around Bar-Code Medication
Administration: An Evidence-Based Evaluation Framework. J Nurs Adm. 2016;46(1):30-7.
doi:10…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Cunningham_11.pdf
January 29, 2008 - because despite system changes, they
remain devastating in terms of their overall high frequency of occurrence … reported in medical journals suggests hospitals have been
implementing OBM strategies to increase the occurrence … negative outcome,73 it also adds a patient-centered, customized set of cues to
13
prompt the occurrence
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/hotline/healthcare-safety-hotline-appendixc.pdf
July 01, 2015 - Only simple tabulations of the reported
safety occurrence (RSO) data from patient/family/caregiver reports … The main data entity is called a reported safety occurrence (RSO). … Similarly, patients who report the occurrence of a negative effect will be directed to the
section of … Patients and
caregivers who report the occurrence of a medical mistake will be prompted to answer whether … Health Care Safety Hotline
Classification of Reported Safety Occurrence (RSO)
-------------------
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www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/heart-health/primary-prevention-cvd-with-statins.pdf
June 02, 2025 - incomplete adherence including costs, the lack of benefit
that a patient can see or feel, and the occurrence
-
psnet.ahrq.gov/node/40304/psn-pdf
March 23, 2011 - Bar code medication administration technology:
characterization of high-alert medication triggers and
clinician workarounds.
March 23, 2011
Miller DF, Fortier CR, Garrison KL. Bar Code Medication Administration Technology: Characterization of
High-Alert Medication Triggers and Clinician Workarounds. Ann Pharmacoth…
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psnet.ahrq.gov/node/37776/psn-pdf
January 31, 2011 - Barcoded medication administration: a last line of
defense.
January 31, 2011
Cescon DW, Etchells E. Barcoded medication administration: a last line of defense. JAMA.
2008;299(18):2200-2. doi:10.1001/jama.299.18.2200.
https://psnet.ahrq.gov/issue/barcoded-medication-administration-last-line-defense
Barcoding techn…