Results

Total Results: 4,038 records

Showing results for "occurs".

121. Serious Reportable Events in Healthcare—2011 Update. | PSNet
     psnet.ahrq.gov/issue/serious-reportable-events-healthcare-2011-update
     March 23, 2012 - When such an event occurs, many institutions mandate performance of a root cause analysis .

122. Creating highly reliable health care: how reliability-enhancing work practices affect patient safety in hospitals. | PSNet
     psnet.ahrq.gov/issue/creating-highly-reliable-health-care-how-reliability-enhancing-work-practices-affect-patient
     January 12, 2022 - within high-risk industries that have adopted processes to detect and address failures before harm occurs

123. Organizational learning: health care leaders need to design structures and processes that enhance collective learning. | PSNet
     psnet.ahrq.gov/issue/organizational-learning-health-care-leaders-need-design-structures-and-processes-enhance
     November 18, 2020 - The authors argue that true learning in health organizations occurs through a cyclical, dualistic, and

124. Team cognition in handoffs: relating system factors, team cognition functions and outcomes in two handoff processes. | PSNet
     psnet.ahrq.gov/issue/team-cognition-handoffs-relating-system-factors-team-cognition-functions-and-outcomes-two
     February 16, 2022 - This qualitative study explores how team cognition occurs during care transitions and interprofessional

125. Stakeholder perceptions of and attitudes towards problematic polypharmacy and prescribing cascades: a qualitative study. | PSNet
     psnet.ahrq.gov/issue/stakeholder-perceptions-and-attitudes-towards-problematic-polypharmacy-and-prescribing
     July 10, 2019 - An unintentional prescribing cascade occurs when a medication side effect is misinterpreted as a new

126. Racial and ethnic harm in patient care is a patient safety issue. | PSNet
     psnet.ahrq.gov/issue/racial-and-ethnic-harm-patient-care-patient-safety-issue
     October 21, 2020 - ethnically marginalized patients, such as antiracism education and addressing harm promptly when it occurs

127. Standardized assessment of medication reconciliation in post-acute care. | PSNet
     psnet.ahrq.gov/issue/standardized-assessment-medication-reconciliation-post-acute-care
     December 16, 2020 - Medication reconciliation (MR) occurs during transitions of care and is the process of reviewing a patient

128. The effect of clinical experience on the error rate of emergency physicians. | PSNet
     psnet.ahrq.gov/issue/effect-clinical-experience-error-rate-emergency-physicians
     November 16, 2022 - often examined by conducting case reviews or root cause analyses when an undesired patient outcome occurs

129. Ten years later, alarm fatigue is still a safety concern. | PSNet
     psnet.ahrq.gov/issue/ten-years-later-alarm-fatigue-still-safety-concern
     October 25, 2023 - Alarm (or alert) fatigue occurs when clinicians ignore alarms, usually due to the majority being invalid

130. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49581/psn-pdf
     March 21, 2009 - operationalized; however, the far-reaching effects of these decisions often go undetected until an error occurs … The error occurs when individuals fall victim to the flaws within the system and mistakes are made. … Standardize patient-centric handoff communication, and mandate that it occurs at the time of nursing

131. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49628/psn-pdf
     June 01, 2011 - The most commonly cited preoperative risk is bleeding, which occurs in up to 3% of patients. … The highest risk of return to the operating room to control hemorrhage occurs one week postoperatively … The most common complication is postoperative bleeding, which occurs in less than 10% of patients.

132. Methicillin-resistant Staphylococcus aureus disease in three communities. | PSNet
     psnet.ahrq.gov/issue/methicillin-resistant-staphylococcus-aureus-disease-three-communities
     July 03, 2014 - data indicates that acquisition of methicillin-resistant Staphylococcus aureus (MRSA) infection now occurs

133. Nurses' safety motivation: examining predictors of nurses' willingness to report medication errors. | PSNet
     psnet.ahrq.gov/issue/nurses-safety-motivation-examining-predictors-nurses-willingness-report-medication-errors
     October 10, 2015 - that nurses are more willing to report medication errors if they perceive that feedback on errors occurs

134. The medical emergency team system: a two hospital comparison. | PSNet
     psnet.ahrq.gov/issue/medical-emergency-team-system-two-hospital-comparison
     January 15, 2009 - further risk assess patients who may benefit from increased monitoring before a clinical deterioration occurs

135. Current approaches to punitive action for medication errors by boards of pharmacy. | PSNet
     psnet.ahrq.gov/issue/current-approaches-punitive-action-medication-errors-boards-pharmacy
     May 26, 2011 - This occurs despite a consensus that such punitive measures are unlikely to improve patient safety.

136. Prescription of teratogenic medications in United States ambulatory practices. | PSNet
     psnet.ahrq.gov/issue/prescription-teratogenic-medications-united-states-ambulatory-practices
     March 23, 2012 - prescribing patterns of potentially dangerous medications to nonpregnant young women, suggesting it occurs

137. When doing wrong feels so right: normalization of deviance. | PSNet
     psnet.ahrq.gov/issue/when-doing-wrong-feels-so-right-normalization-deviance
     September 03, 2011 - This commentary explains the concept of normalization of deviance, which occurs when poor processes are

138. “Those found responsible have been sacked”: some observations on the usefulness of error. | PSNet
     psnet.ahrq.gov/issue/those-found-responsible-have-been-sacked-some-observations-usefulness-error
     September 28, 2010 - improvement, but the concept isn’t universally accepted as an approach to determine the foci of how failure occurs

139. Ethics in the pediatric emergency department: when mistakes happen: an approach to the process, evaluation, and response to medical errors. | PSNet
     psnet.ahrq.gov/issue/ethics-pediatric-emergency-department-when-mistakes-happen-approach-process-evaluation-and
     December 13, 2013 - The authors also explore the evidence on transparency in the ED when an error occurs and how to make

140. Blind Spot | PSNet
     psnet.ahrq.gov/web-mm/blind-spot
     July 30, 2020 - Specific ophthalmologic findings determine the diagnosis.( 5 ) AION occurs at the optic nerve head as … PION occurs anywhere posterior to the optic nerve head to the optic nerve chiasm. … Figure 2 ) with their eyes free from external pressure.( 6 ) These data clearly demonstrate that ION occurs … Cortical blindness is usually associated with embolic events or profound hypotension and most commonly occurs