Results

Total Results: 4,038 records

Showing results for "occurs".

141. 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.

142. 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

143. 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

144. 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

145. 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

146. 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

147. 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.

148. 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

149. 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

150. 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

151. 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

152. 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

153. Creating a safer health care system: finding the constraint. | PSNet
     psnet.ahrq.gov/issue/creating-safer-health-care-system-finding-constraint
     February 24, 2011 - The authors argue that sustained change occurs only when these root causes receive appropriate exploration

154. 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

155. 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

156. 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

157. 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

158. Medicare payment for selected adverse events: building the business case for investing in patient safety. | PSNet
     psnet.ahrq.gov/issue/medicare-payment-selected-adverse-events-building-business-case-investing-patient-safety
     September 18, 2009 - , these data revealed that hospitals generally do not receive additional compensation when an error occurs

159. 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

160. Utilizing pharmacy students in transitions-of-care services. | PSNet
     psnet.ahrq.gov/issue/utilizing-pharmacy-students-transitions-care-services
     October 19, 2022 - October 19, 2022 Type 1 diabetes defined by severe insulin deficiency occurs after 30