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Total Results: 4,035 records

Showing results for "occurring".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44208/psn-pdf
    July 16, 2015 - Preventability of voluntarily reported or trigger tool–identified medication errors in a pediatric institution by information technology: a retrospective cohort study. July 16, 2015 Stultz JS, Nahata MC. Preventability of Voluntarily Reported or Trigger Tool-Identified Medication Errors in a Pediatric Institution …

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46774/psn-pdf
    April 12, 2019 - Association between handover of anesthesia care and adverse postoperative outcomes among patients undergoing major surgery. April 12, 2019 Jones PM, Cherry RA, Allen BN, et al. Association Between Handover of Anesthesia Care and Adverse Postoperative Outcomes Among Patients Undergoing Major Surgery. JAMA. 2018;319…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44112/psn-pdf
    November 03, 2015 - Unexpected death within 72 hours of emergency department visit: were those deaths preventable? November 3, 2015 Goulet H, Guerand V, Bloom B, et al. Unexpected death within 72 hours of emergency department visit: were those deaths preventable? Crit Care. 2015;19(1):154. doi:10.1186/s13054-015-0877-x. https://psnet…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44064/psn-pdf
    November 03, 2015 - The July effect: an analysis of never events in the nationwide inpatient sample. November 3, 2015 Wen T, Attenello FJ, Wu B, et al. The July effect: an analysis of never events in the nationwide inpatient sample. J Hosp Med. 2015;10(7):432-438. doi:10.1002/jhm.2352. https://psnet.ahrq.gov/issue/july-effect-analysi…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42711/psn-pdf
    October 31, 2014 - Characterising the complexity of medication safety using a human factors approach: an observational study in two intensive care units. October 31, 2014 Carayon P, Wetterneck TB, Cartmill R, et al. Characterising the complexity of medication safety using a human factors approach: an observational study in two inten…

  6. 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

  7. 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].

  8. 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

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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

  16. 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

  17. 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

  18. 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.

  19. 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

  20. Right Patient, Wrong Sample | PSNet

    psnet.ahrq.gov/web-mm/right-patient-wrong-sample
    June 01, 2004 - The Commentary Background Errors in laboratory services encompass a number of problems occurring outside … 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
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