Results

Total Results: 4,038 records

Showing results for "occurring".

181. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36366/psn-pdf
     April 11, 2011 - Adverse events were relatively common, occurring at a rate of 0.74 per patient, most of which were preventable

182. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38411/psn-pdf
     December 16, 2014 - reengineered-hospital-discharge-program-decrease-rehospitalization- randomized-trial Adverse events after hospital discharge are disturbingly common, occurring

183. Elopement: evidence-based mitigation and management. | PSNet
     psnet.ahrq.gov/issue/elopement-evidence-based-mitigation-and-management
     October 19, 2022 - After implementation, the number of elopements occurring over a six-month period decreased from 34 to

184. Zero harm in health care. | PSNet
     psnet.ahrq.gov/issue/zero-harm-health-care
     August 12, 2020 - non-physical harms (e.g., psychological harms), harms to caregivers and the healthcare workforce, and harms occurring

185. Investigation of urology intraoperative events leading to root cause analysis at national VA medical centers. | PSNet
     psnet.ahrq.gov/issue/investigation-urology-intraoperative-events-leading-root-cause-analysis-national-va-medical
     June 02, 2021 - Using RCA data from the Veterans Health Administration (VHA), this study characterized adverse events occurring

186. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43016/psn-pdf
     May 28, 2014 - home care adverse event reporting system, analogous to state reporting systems for serious errors occurring

187. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40904/psn-pdf
     January 04, 2012 - An AHRQ WebM&M commentary discusses a case of a medication error occurring in an acutely ill patient

188. Improving Safety and Security for Veterans Act of 2020. | PSNet
     psnet.ahrq.gov/issue/improving-safety-and-security-veterans-act-2020
     March 25, 2020 - June 22, 2007 Preventable harm occurring to critically ill children.

189. Errors originating in hospital and health-system outpatient pharmacies. | PSNet
     psnet.ahrq.gov/issue/errors-originating-hospital-and-health-system-outpatient-pharmacies
     December 19, 2016 - According to this analysis of more than 1000 reports of errors occurring in community pharmacies , more

190. Patient safety incidents are common in primary care: a national prospective active incident reporting survey. | PSNet
     psnet.ahrq.gov/issue/patient-safety-incidents-are-common-primary-care-national-prospective-active-incident
     July 24, 2024 - prospective study elicited incident reports from general practitioners for all types of adverse events occurring

191. Impact of nighttime rapid response team activation on outcomes of hospitalized patients with acute deterioration. | PSNet
     psnet.ahrq.gov/issue/impact-nighttime-rapid-response-team-activation-outcomes-hospitalized-patients-acute
     April 06, 2022 - A previous WebM&M commentary discussed a preventable adverse event occurring in part due to less intensive

192. Medication errors' causes analysis in home care setting: a systematic review. | PSNet
     psnet.ahrq.gov/issue/medication-errors-causes-analysis-home-care-setting-systematic-review
     August 17, 2022 - Causes of medication errors occurring in home care may differ from those in the hospital setting.

193. Register-based research of adverse events revealing incomplete records threatening patient safety. | PSNet
     psnet.ahrq.gov/issue/register-based-research-adverse-events-revealing-incomplete-records-threatening-patient
     October 06, 2021 - retrospective review of patient incident reports in Finland found that nearly half of the 82,353 incidents occurring

194. Multiple points of system failure underpin continuous subcutaneous infusion safety incidents in palliative care: a mixed methods analysis. | PSNet
     psnet.ahrq.gov/issue/multiple-points-system-failure-underpin-continuous-subcutaneous-infusion-safety-incidents
     December 16, 2020 - Approximately 72% described harms with breakdowns occurring in three processes: monitoring and supply

195. A retrospective review of serious surgical incidents in 5 large UK teaching hospitals: a system-based approach. | PSNet
     psnet.ahrq.gov/issue/retrospective-review-serious-surgical-incidents-5-large-uk-teaching-hospitals-system-based
     May 26, 2021 - This study reviewed serious surgical incidents occurring at large teaching hospitals in one National

196. Maternal sleepiness and risk of infant drops in the postpartum period. | PSNet
     psnet.ahrq.gov/issue/maternal-sleepiness-and-risk-infant-drops-postpartum-period
     October 19, 2022 - Nursing observations and formal assessments of mothers' sleepiness prevented infant drops from occurring

197. Enteral nutrition: an underappreciated source of patient safety events. | PSNet
     psnet.ahrq.gov/issue/enteral-nutrition-underappreciated-source-patient-safety-events
     February 01, 2023 - Enteral nutrition (EN) therapies are vulnerable to the same types of errors as those occurring in the

198. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39116/psn-pdf
     April 30, 2014 - missed or delayed diagnoses were pulmonary embolism and drug reactions or overdose, with the errors occurring

199. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41223/psn-pdf
     March 21, 2012 - the role of England's Care Quality Commission in their own regulatory investigation of major issues occurring

200. Hearing: Broken Promises: Assessing VA’s Systems for Protecting Veterans from Clinical Harm. | PSNet
     psnet.ahrq.gov/issue/hearing-broken-promises-assessing-vas-systems-protecting-veterans-clinical-harm
     December 23, 2012 - This hearing examined a series of problems occurring in the VA system including unexplained deaths of