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Showing results for "occurrence".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35160/psn-pdf
    January 02, 2017 - Unlabeled containers lead to patient's death. January 2, 2017 Cohen MR, Smetzer JL. Unlabeled containers lead to patient's death. Jt Comm J Qual Patient Saf. 2005;31(7):414-7. https://psnet.ahrq.gov/issue/unlabeled-containers-lead-patients-death The authors review selected incidents of harm involving unlabeled con…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35161/psn-pdf
    March 13, 2016 - The forgotten tourniquet—an update. March 13, 2016 PA Patient Saf Advis. 2016;13(1):4. http://patientsafety.pa.gov/ADVISORIES/Pages/201603_32.aspx. https://psnet.ahrq.gov/issue/forgotten-tourniquet-update This advisory from the Pennsylvania Patient Safety Reporting System discusses 1079 reports of tourniquets bein…

  3. Rapid Response: Efficacy of Dental Services for Reducing Adverse Events in Those Receiving Chemotherapy for Cancer (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/related_files/rapid-response-chemotherapy-dental.pdf
    July 01, 2023 - Published series of affected patients have identified the major risk factors for its occurrence to be … some cancer patients, and early dental evaluation and treatment can potentially reduce its rate of occurrence … Three uncontrolled studies reported on infection occurrence in cohorts (2 prospective and 1 retrospective … The five comparative studies that addressed the effect of pre-treatment dental care on the occurrence … Decreased occurrence of osteonecrosis of the jaw after implementation of dental preventive measures

  4. Final Progress Report: Further Psychometric Testing and Validation of the Errors of Care Omission Survey (ECOS) (pdf file)

    www.ahrq.gov/sites/default/files/2025-02/poghosyan-report.pdf
    January 01, 2025 - capabilities, such as presence of reminder systems or decision support tools in practices on the occurrence

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35932/psn-pdf
    October 03, 2017 - Injury to research volunteers—the clinical-research nightmare. October 3, 2017 Wood AJJ, Darbyshire J. Injury to research volunteers--the clinical-research nightmare. N Engl J Med. 2006;354(18):1869-71. https://psnet.ahrq.gov/issue/injury-research-volunteers-clinical-research-nightmare The authors discuss a high-…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37915/psn-pdf
    January 27, 2009 - Barcode technology flaws put some patients at risk. January 27, 2009 Preidt R. ABC News. July 4, 2008. https://psnet.ahrq.gov/issue/barcode-technology-flaws-put-some-patients-risk This article discusses the findings of a recent study that reported deficiencies in barcode systems requiring numerous overrides a…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49726/psn-pdf
    March 01, 2015 - incorrect level.(2) Wrong-site surgery has long been recognized as a sentinel event—an unexpected occurrence

  8. Articulate Word Output (pdf file)

    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

  9. Readmissions to U.S. Hospitals by Procedure, 2010 (pdf file)

    hcup-us.ahrq.gov/reports/statbriefs/sb154.pdf
    March 01, 2013 - Readmissions to U.S. Hospitals by Procedure, 2010 1 April 2013 Readmissions to U.S. Hospitals by Procedure, 2010 Audrey J. Weiss, Ph.D., Anne Elixhauser, Ph.D., and Claudia Steiner, M.D., M.P.H. Introduction Readmissions—revisits to the hospital within a certain time frame following an…

  10. Wrong-side thoracentesis: lessons learned from root cause analysis. | PSNet

    psnet.ahrq.gov/issue/wrong-side-thoracentesis-lessons-learned-root-cause-analysis
    July 16, 2015 - Study Wrong-side thoracentesis: lessons learned from root cause analysis. Citation Text: Miller K, Mims M, Paull DE, et al. Wrong-side thoracentesis: lessons learned from root cause analysis. JAMA Surg. 2014;149(8):774-9. doi:10.1001/jamasurg.2014.146. Copy Citation Format: …

  11. Burn-Related Hospital Inpatient Stays and Emergency Department Visits, 2013 (pdf file)

    hcup-us.ahrq.gov/reports/statbriefs/sb217-Burn-Hospital-Stays-ED-Visits-2013.pdf
    January 01, 2013 - codes, with the exception of E000, External cause status; E001–E030, Activity; and E849, Place of occurrence … codes, with the exception of E000, External cause status; E001–E030, Activity; and E849, Place of occurrence … injury codes (E codes) except E000, External cause status; E001–E030, Activity; and E849, Place of occurrence

  12. Burn-Related Hospital Inpatient Stays and Emergency Department Visits, 2013 #217

    hcup-us.ahrq.gov/reports/statbriefs/sb217-Burn-Hospital-Stays-ED-Visits-2013.jsp
    December 01, 2016 - E codes, with the exception of E000, External cause status; E001-E030, Activity; and E849, Place of occurrence … E codes, with the exception of E000, External cause status; E001-E030, Activity; and E849, Place of occurrence … injury codes (E codes) except E000, External cause status; E001-E030, Activity; and E849, Place of occurrence

  13. Clinical Inertia and Outpatient Medical Errors (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/OConnor.pdf
    January 01, 2003 - hemoglobin (A1c), low-density lipoprotein-cholesterol (LDL), and SBP control.12, 15 Cost The frequent occurrence … SBP 10 mm Hg above 150 mm Hg, there will be 1 additional heart attack or stroke, plus 1 additional occurrence … , but it also provides a strong element of accountability to providers who must justify a specific occurrence

  14. pneumonia-antibiotic-treatment-protocol-130718 (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/pdf/pneumonia-antibiotic-treatment_research-protocol.pdf
    July 19, 2013 - o KQ 1a, KQ 2a, and KQ 3: Intermediate outcomes  Clinical response  Mechanical ventilation (occurrence … Susceptibility (KQ 3)     Intermediate Outcomes • Clinical response • Mechanical ventilation (occurrence … Outcomes • KQ 1a, KQ 2a, and KQ 3 o Intermediate:  Clinical response  Mechanical ventilation (occurrence

  15. Slide 1

    effectivehealthcare.ahrq.gov/sites/default/files/exposure-definition-and-measurement_chapter-4.pptx
    January 01, 2013 - Frequency, amount/dose of each occurrence, and duration of exposure It is applicable to medications and … Three elements are necessary to calculate cumulative dose: 1) frequency, 2) amount/dose of each occurrence

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38348/psn-pdf
    December 30, 2014 - Implementing a bar-code medication administration system. December 30, 2014 Weber RJ. Implementing a Bar-Code Medication Administration System. Hosp Pharm. 2010;43(12):1016- 1022. doi:10.1310/hpj4312-1016. https://psnet.ahrq.gov/issue/implementing-bar-code-medication-administration-system This commentary discusse…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849613/psn-pdf
    May 31, 2023 - Smart infusion pump investigations after an unexplained over-infusion. May 31, 2023 ISMP Patient Safety Alert! Acute care edition. May 18, 2023;28(10);1-3. https://psnet.ahrq.gov/issue/smart-infusion-pump-investigations-after-unexplained-over-infusion Dose error-reduction systems (DERS) and drug libraries are tool…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42767/psn-pdf
    November 27, 2013 - Barcode medication administration work-arounds: a systematic review and implications for nurse executives. November 27, 2013 Voshall B, Piscotty R, Lawrence J, et al. Barcode medication administration work-arounds: a systematic review and implications for nurse executives. J Nurs Adm. 2013;43(10):530-535. doi:10.1…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46593/psn-pdf
    November 08, 2017 - Unreadable barcodes and multiple barcodes on packages can lead to errors. November 8, 2017 ISMP Medication Safety Alert! Acute care edition. October 19, 2017;22:1-3. https://psnet.ahrq.gov/issue/unreadable-barcodes-and-multiple-barcodes-packages-can-lead-errors Barcodes can both enhance and degrade the medication …

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45249/psn-pdf
    June 22, 2016 - PHSO Review: Quality of NHS Complaints Investigations. June 22, 2016 First Report of Session 2016–17 Report. House of Commons Public Administration and Constitutional Affairs Committee. London, England: The Stationery Office; May 24, 2016. Publication HC 94. https://psnet.ahrq.gov/issue/phso-review-quality-nhs-comp…
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