Results

Total Results: 4,038 records

Showing results for "occurs".

121. Ambulatory medication errors and adverse events involved in medicine-related malpractice cases from 2011 to 2021. | PSNet
     psnet.ahrq.gov/issue/ambulatory-medication-errors-and-adverse-events-involved-medicine-related-malpractice-cases
     November 18, 2016 - Most medication safety research occurs in the inpatient setting, with less focus on ambulatory care.

122. 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

123. 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

124. 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

125. 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

126. 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

127. 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

128. 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

129. 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

130. The Inside of a Time Out | PSNet
     psnet.ahrq.gov/web-mm/inside-time-out
     March 01, 2004 - procedure is not started if a member of the team has concerns.( 2 ) In some institutions, the time out occurs … If the time out occurs at the time of incision, the surgeon is already scrubbed in, leaving only the … time out is for the team to collectively discuss the case, but, given the requirements to ensure it occurs … With regard to timing, it seems that the closer to actual incision time the time out occurs, the less

131. Doctors were alarmed: would I have my children have surgery here? | PSNet
     psnet.ahrq.gov/issue/doctors-were-alarmed-would-i-have-my-children-have-surgery-here
     February 19, 2020 - November 9, 2022 Misdiagnosis of thoracic aortic emergencies occurs frequently among

132. 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

133. 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

134. 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

135. 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

136. “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

137. 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

138. 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

139. 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.

140. Reducing the Risks of Wrong-Site Surgery: Safety Practices from The Joint Commission Center for Transforming Healthcare Project. | PSNet
     psnet.ahrq.gov/issue/reducing-risks-wrong-site-surgery-safety-practices-joint-commission-center-transforming
     October 19, 2016 - Wrong-site surgery is a never event , but still occurs at alarming rates.