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Total Results: 4,038 records

Showing results for "occurring".

1801. The Wrong Shot: Error Disclosure | PSNet
      psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure
      May 01, 2011 - SPOTLIGHT CASE The Wrong Shot: Error Disclosure Citation Text: Gallagher TH, Levinson W. The Wrong Shot: Error Disclosure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Sch…

1802. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49669/psn-pdf
      November 01, 2012 - Transfusion Overload November 1, 2012 Patel MS, Carson JL. Transfusion Overload. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/transfusion-overload Case Objectives Understand that the traditional transfusion thresholds of hemoglobin below 10 g/dL and hematocrit below 30% are not supported by the evidence.…

1803. Resuscitation Errors: A Shocking Problem | PSNet
      psnet.ahrq.gov/web-mm/resuscitation-errors-shocking-problem
      October 19, 2022 - SPOTLIGHT CASE Resuscitation Errors: A Shocking Problem Citation Text: Edelson DP, Abella BS. Resuscitation Errors: A Shocking Problem. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: …

1804. Delay in Initiating Antibiotics Results in Fatal Error | PSNet
      psnet.ahrq.gov/web-mm/delay-initiating-antibiotics-results-fatal-error
      August 02, 2015 - SPOTLIGHT CASE Delay in Initiating Antibiotics Results in Fatal Error Citation Text: Bellini LM. Delay in Initiating Antibiotics Results in Fatal Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation …

1805. Navigating Complications: The Unintended Journey of a Guidewire During Dialysis Catheter Placement | PSNet
      psnet.ahrq.gov/web-mm/navigating-complications-unintended-journey-guidewire-during-dialysis-catheter-placement
      February 23, 2022 - Navigating Complications: The Unintended Journey of a Guidewire During Dialysis Catheter Placement Citation Text: Vuyyuru S, Kapa N. Navigating Complications: The Unintended Journey of a Guidewire During Dialysis Catheter Placement. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qualit…

1806. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38611/psn-pdf
      February 15, 2011 - Effect of an electronic medication reconciliation application and process redesign on potential adverse drug events: a cluster-randomized trial. February 15, 2011 Schnipper JL, Hamann C, Ndumele CD, et al. Effect of an electronic medication reconciliation application and process redesign on potential adverse drug …

1807. Multimodal system designed to reduce errors in recording and administration of drugs in anaesthesia: prospective randomised clinical evaluation. | PSNet
      psnet.ahrq.gov/issue/multimodal-system-designed-reduce-errors-recording-and-administration-drugs-anaesthesia
      September 26, 2012 - March 23, 2011 Medication errors occurring with the use of bar-code administration technology

1808. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.84_slideshow.ppt
      December 01, 2004 - Adverse drug events occurring following hospital discharge [abstract]. … Adverse drug events occurring following hospital discharge [abstract].

1809. Can asking emergency physicians whether or not they would have done something differently (WYHDSD) be a useful screening tool to identify emergency department error? | PSNet
      psnet.ahrq.gov/issue/can-asking-emergency-physicians-whether-or-not-they-would-have-done-something-differently
      July 01, 2016 - January 26, 2022 Analysis of risk factors for patient safety events occurring in the

1810. Supratherapeutic dosing of acetaminophen among hospitalized patients. | PSNet
      psnet.ahrq.gov/issue/supratherapeutic-dosing-acetaminophen-among-hospitalized-patients
      February 14, 2017 - October 30, 2010 Medication errors occurring with the use of bar-code administration

1811. Inadequacies of physical examination as a cause of medical errors and adverse events: a collection of vignettes. | PSNet
      psnet.ahrq.gov/issue/inadequacies-physical-examination-cause-medical-errors-and-adverse-events-collection
      June 01, 1989 - April 22, 2015 Baccalaureate nursing students' accounts of medical mistakes occurring

1812. Improving health care quality and patient safety through peer-to-peer assessment: demonstration project in two academic medical centers. | PSNet
      psnet.ahrq.gov/issue/improving-health-care-quality-and-patient-safety-through-peer-peer-assessment-demonstration
      March 14, 2018 - September 29, 2021 Systematic evaluation of errors occurring during the preparation of

1813. Root cause analysis of serious adverse events among older patients in the Veterans Health Administration. | PSNet
      psnet.ahrq.gov/issue/root-cause-analysis-serious-adverse-events-among-older-patients-veterans-health
      August 02, 2015 - April 12, 2019 Root cause analyses of reported adverse events occurring during gastrointestinal

1814. Missed serious neurologic conditions in emergency department patients discharged with nonspecific diagnoses of headache or back pain. | PSNet
      psnet.ahrq.gov/issue/missed-serious-neurologic-conditions-emergency-department-patients-discharged-nonspecific
      April 08, 2018 - March 19, 2019 Analysis of risk factors for patient safety events occurring in the emergency

1815. Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients. | PSNet
      psnet.ahrq.gov/issue/root-cause-analysis-reports-help-identify-common-factors-delayed-diagnosis-and-treatment
      October 24, 2018 - April 12, 2019 Root cause analyses of reported adverse events occurring during gastrointestinal

1816. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49527/psn-pdf
      December 01, 2006 - The Commentary Background Errors in laboratory services encompass a number of problems occurring outside … physicians often attribute to errors inside the laboratory, are actually the result of preanalytic problems occurring … Specific Errors in This Case The particular error in this case is a mislabeling error occurring outside

1817. The Safety and Quality of Long Term Care | PSNet
      psnet.ahrq.gov/web-mm/safety-and-quality-long-term-care
      January 01, 2016 - warrants close assessment and aggressive management by nursing staff to prevent serious breakdown from occurring … constitute nearly 10% of Medicare admissions to acute care, with nearly 40% of these hospitalizations occurring … taking high risk medications such as anticoagulants are monitored daily to assure no adverse events are occurring

1818. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49830/psn-pdf
      May 01, 2018 - In a recent study of adverse events occurring on mental health units in the Veterans Health Administration … Adverse events occurring on VHA mental health units. Gen Hosp Psychiatry. 2018;50:63-68.

1819. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33687/psn-pdf
      August 01, 2009 - downside of first-order problem solving is lack of communication, which hinders real improvement from occurring … Even this meager form of second-order problem solving was rare, occurring in only 7% of the situations

1820. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49650/psn-pdf
      March 01, 2012 - The most recent analysis described 46 deaths and 263 procedure-related complications occurring from … references https://psnet.ahrq.gov//#references Quality improvement strategies to prevent these events from occurring