Results

Total Results: 4,038 records

Showing results for "occurs".

141. 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 .

142. Routine Goes Awry | PSNet
     psnet.ahrq.gov/web-mm/routine-goes-awry
     September 23, 2020 - 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.

143. Never Events | PSNet
     psnet.ahrq.gov/primer/never-events
     June 15, 2024 - other than as intended Patient death or serious injury associated with intravascular air embolism that occurs … serious injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs

144. Risks in the analogue and digitally-supported medication process and potential solutions to increase patient safety in the hospital: a mixed methods study. | PSNet
     psnet.ahrq.gov/issue/risks-analogue-and-digitally-supported-medication-process-and-potential-solutions-increase
     April 24, 2019 - In both processes, experts identified that the most critical risk of errors and harm occurs at admission

145. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49589/psn-pdf
     August 01, 2009 - Background Herpes zoster (or shingles) occurs in approximately 1 million people annually in the United … Or, when HZ occurs fully or partially under the scalp, it can also lead to a missed diagnosis. … Unilateral allergic contact dermatitis, as often occurs with cases of poison ivy, is also in the differential

146. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. | PSNet
     psnet.ahrq.gov/issue/national-trauma-care-system-integrating-military-and-civilian-trauma-systems-achieve-zero
     September 12, 2018 - Large system failure occurs when such interventions are not disseminated and implemented.

147. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/846169/psn-pdf
     March 15, 2023 - anesthesia, including the postoperative period.1 It is a potentially life-threatening complication that occurs … to prevent negative pressure pulmonary edema and/or hypoxic cardiac arrest.6 Laryngospasm usually occurs … sedation and anesthesia must be vigilant and competent to rapidly diagnose and treat laryngospasm, if it occurs … Capillary rupture occurs because of excessive negative pressure created in the lung when the patient

148. Role of cognition in generating and mitigating clinical errors. | PSNet
     psnet.ahrq.gov/issue/role-cognition-generating-and-mitigating-clinical-errors
     January 07, 2015 - approaches like virtual reality simulation to train physicians to manage cognitive error once it occurs

149. The impact of safety organizing, trusted leadership, and care pathways on reported medication errors in hospital nursing units. | PSNet
     psnet.ahrq.gov/issue/impact-safety-organizing-trusted-leadership-and-care-pathways-reported-medication-errors
     January 18, 2011 - organizations should avoid focusing on technical and organizational factors in isolation, as benefit occurs

150. Conspicuous by its absence: diagnostic expert testing under uncertainty. | PSNet
     psnet.ahrq.gov/issue/conspicuous-its-absence-diagnostic-expert-testing-under-uncertainty
     February 28, 2024 - June 7, 2023 Misdiagnosis of thoracic aortic emergencies occurs frequently among transfers

151. Role of knowledge and reasoning processes as predictors of resident physicians' susceptibility to anchoring bias in diagnostic reasoning: a randomised controlled experiment. | PSNet
     psnet.ahrq.gov/issue/role-knowledge-and-reasoning-processes-predictors-resident-physicians-susceptibility
     March 18, 2020 - Anchoring bias occurs when a physician relies on their initial diagnostic impression despite subsequent

152. Health system redesign of cardiac monitoring oversight to optimize alarm management, safety, and staff engagement. | PSNet
     psnet.ahrq.gov/issue/health-system-redesign-cardiac-monitoring-oversight-optimize-alarm-management-safety-and
     February 15, 2023 - Alert fatigue occurs when healthcare workers become desensitized to alarms over time, especially when

153. Inattentional blindness in anesthesiology: a gorilla is worth one thousand words. | PSNet
     psnet.ahrq.gov/issue/inattentional-blindness-anesthesiology-gorilla-worth-one-thousand-words
     June 01, 2022 - Inattentional blindness occurs when individuals miss an unexpected event due to competing attentional

154. Creating a culture of safety by coaching clinicians to competence. | PSNet
     psnet.ahrq.gov/issue/creating-culture-safety-coaching-clinicians-competence
     January 10, 2024 - November 9, 2022 Type 1 diabetes defined by severe insulin deficiency occurs after 30

155. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866826/psn-pdf
     September 25, 2024 - When this happens, desaturation occurs very quickly. … rule out a hypoxic gas mixture whenever they encounter very rapid desaturation or when desaturation occurs … seen the effect of administering a hypoxic gas mixture because cross- connection of the gas supply occurs … Have a low threshold to change to a different gas supply Whenever desaturation occurs very rapidly,

156. Second Victims: Support for Clinicians Involved in Errors and Adverse Events | PSNet
     psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events
     December 15, 2024 - When a medical error or patient harm occurs, the first priority is to attend to the patient and family … errors and adverse events, along with support that can be put in place to respond when such involvement occurs

157. Teaching medical error disclosure to physicians-in-training: a scoping review. | PSNet
     psnet.ahrq.gov/issue/teaching-medical-error-disclosure-physicians-training-scoping-review
     June 09, 2015 - This in part occurs because training in error disclosure is not a standard component of medical school

158. COVID-19 has united patients and providers against institutional betrayal in health care: a battle to be heard, believed, and protected. | PSNet
     psnet.ahrq.gov/issue/covid-19-has-united-patients-and-providers-against-institutional-betrayal-health-care-battle
     June 29, 2009 - Institutional betrayal occurs when a patient (or other individual) experiences a harm and the (health

159. Requirements for implementing a 'just culture' within healthcare organisations: an integrative review. | PSNet
     psnet.ahrq.gov/issue/requirements-implementing-just-culture-within-healthcare-organisations-integrative-review
     October 31, 2014 - just culture ” balances organizational responsibility and individual accountability after an error occurs

160. Comfort with uncertainty: reframing our conceptions of how clinicians navigate complex clinical situations. | PSNet
     psnet.ahrq.gov/issue/comfort-uncertainty-reframing-our-conceptions-how-clinicians-navigate-complex-clinical
     February 06, 2013 - and suggests that individual awareness of uncertainty is required to respond to the condition as it occurs