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Total Results: 4,038 records

Showing results for "occurs".

161. 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

162. 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

163. Distraction of the Anesthesiologist and Lack of Resuscitation Drugs Resulting in Delayed Treatment of Laryngospasm. | PSNet
     psnet.ahrq.gov/web-mm/distraction-anesthesiologist-and-lack-resuscitation-drugs-resulting-delayed-treatment
     January 29, 2021 - 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

164. Hiding in Plain Sight | PSNet
     psnet.ahrq.gov/web-mm/hiding-plain-sight
     April 24, 2019 - 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

165. BONE break: a hot debrief tool to reduce second victim syndrome for nurses. | PSNet
     psnet.ahrq.gov/issue/bone-break-hot-debrief-tool-reduce-second-victim-syndrome-nurses
     August 02, 2015 - " Second victim syndrome " occurs when an adverse event or error has a negative emotional impact

166. Impact of initial hospital diagnosis on mortality for acute myocardial infarction: a national cohort study. | PSNet
     psnet.ahrq.gov/issue/impact-initial-hospital-diagnosis-mortality-acute-myocardial-infarction-national-cohort-study
     April 19, 2017 - Misdiagnosis or delayed diagnosis of common conditions, such as acute myocardial infarction (AMI), occurs

167. Predictors and triggers of incivility within healthcare teams: a systematic review of the literature. | PSNet
     psnet.ahrq.gov/issue/predictors-and-triggers-incivility-within-healthcare-teams-systematic-review-literature
     July 21, 2011 - Studies generally found that incivility occurs mainly within professional disciplines rather than across

168. Why do hundreds of US women die annually in childbirth? | PSNet
     psnet.ahrq.gov/issue/why-do-hundreds-us-women-die-annually-childbirth
     June 14, 2019 - Resources From the Same Author(s) Type 1 diabetes defined by severe insulin deficiency occurs

169. 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

170. Standardised proformas improve patient handover: audit of trauma handover practice. | PSNet
     psnet.ahrq.gov/issue/standardised-proformas-improve-patient-handover-audit-trauma-handover-practice
     October 19, 2022 - April 24, 2018 Type 1 diabetes defined by severe insulin deficiency occurs after 30 years

171. Infrequent physician use of implantable cardioverter-defibrillators risks patient safety. | PSNet
     psnet.ahrq.gov/issue/infrequent-physician-use-implantable-cardioverter-defibrillators-risks-patient-safety
     August 28, 2019 - March 29, 2023 Misdiagnosis of thoracic aortic emergencies occurs frequently among transfers

172. What's that sound? Managing alarm fatigue. | PSNet
     psnet.ahrq.gov/issue/whats-sound-managing-alarm-fatigue
     April 26, 2023 - July 5, 2017 Misdiagnosis of thoracic aortic emergencies occurs frequently among transfers

173. Double Dosing, by the Rules | PSNet
     psnet.ahrq.gov/web-mm/double-dosing-rules
     February 03, 2010 - 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

174. Content analysis of nurses' reflections on medication errors in a regional hospital. | PSNet
     psnet.ahrq.gov/issue/content-analysis-nurses-reflections-medication-errors-regional-hospital
     December 23, 2020 - February 15, 2023 Type 1 diabetes defined by severe insulin deficiency occurs after 30

175. Pharmacist-led admission medication reconciliation before and after the implementation of an electronic medication management system. | PSNet
     psnet.ahrq.gov/issue/pharmacist-led-admission-medication-reconciliation-and-after-implementation-electronic
     January 15, 2025 - November 21, 2021 Type 1 diabetes defined by severe insulin deficiency occurs after 30

176. Leaving patients to their own devices? Smart technology, safety and therapeutic relationships. | PSNet
     psnet.ahrq.gov/issue/leaving-patients-their-own-devices-smart-technology-safety-and-therapeutic-relationships
     December 04, 2024 - January 15, 2025 Type 1 diabetes defined by severe insulin deficiency occurs after 30

177. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33635/psn-pdf
     July 01, 2006 - They're also going to make sure that feedback occurs, so that these actions get back to the providers … Once litigation actually occurs, the patient safety responsibility ends, and the risk management process … So, I think the answer is that if I'm sitting in an organization and a terrible event occurs and I look … done all this incredibly hard work and made these changes, and then a nasty horrible sentinel event occurs

178. Look-alike medications in the perioperative setting: scoping review of medication incidents and risk reduction interventions. | PSNet
     psnet.ahrq.gov/issue/look-alike-medications-perioperative-setting-scoping-review-medication-incidents-and-risk
     October 04, 2023 - October 25, 2023 Type 1 diabetes defined by severe insulin deficiency occurs after 30

179. Hypoxic Gas Supply from Cross-Connected Pipelines | PSNet
     psnet.ahrq.gov/web-mm/hypoxic-gas-supply-cross-connected-pipelines
     February 05, 2020 - When this happens, desaturation occurs very quickly. … rule out a hypoxic gas mixture whenever they encounter very rapid desaturation or when desaturation occurs … never 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, or

180. Validity of the Agency for Healthcare Research and Quality Patient Safety Indicators and the Centers for Medicare and Medicaid Hospital-acquired Conditions: a systematic review and meta-analysis. | PSNet
     psnet.ahrq.gov/issue/validity-agency-healthcare-research-and-quality-patient-safety-indicators-and-centers
     June 14, 2017 - These results suggest that unless further development and validation of administrative metrics occurs