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Total Results: 4,038 records

Showing results for "occurs".

241. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33825/psn-pdf
     January 01, 2017 - some state regulatory agencies mandate RCAs after sentinel events and when significant patient harm occurs … Hindsight bias occurs when people investigating a situation already know the outcome.

242. Making Do | PSNet
     psnet.ahrq.gov/web-mm/making-do
     September 05, 2018 - When this sort of improvisation occurs, the surgeon must ensure that the system provides the same level … Even though infection is possible, sepsis rarely occurs after operative hysteroscopy.

243. Health Care Worker Presenteeism: A Challenge for Patient Safety | PSNet
     psnet.ahrq.gov/perspective/health-care-worker-presenteeism-challenge-patient-safety
     November 03, 2015 - and norovirus.( 6 ) Despite how risky health care worker presenteeism is for patients, it commonly occurs … and Knowledge Like many threats to patient safety, the reasons why health care worker presenteeism occurs

244. Nonsustained Ventricular Tachycardia After Acute Coronary Syndromes: Recognizing High-Risk Patients | PSNet
     psnet.ahrq.gov/web-mm/nonsustained-ventricular-tachycardia-after-acute-coronary-syndromes-recognizing-high-risk
     September 20, 2011 - is not associated with increased risk of sudden death or all-cause mortality, particularly when it occurs … In the case of new-onset NSVT, NSVT that is increasing in frequency or duration, or NSVT that occurs

245. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49704/psn-pdf
     March 01, 2014 - Decreased excretion of bilirubin in newborns occurs because it takes time to increase the activity of … Thus, the late anemia occurs due to ongoing hemolysis of the remaining Rh+ cells and because the transfused

246. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49599/psn-pdf
     February 23, 2010 - into two distinct entities: positive and negative.(5) Positive defensive medicine, as in this case, occurs … Negative defensive medicine occurs when physicians curtail services to avoid high-risk patients or procedures

247. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49739/psn-pdf
     August 21, 2015 - Tracheo-esophageal fistula (TEF) occurs in approximately 1 in 1250 patients following tracheostomy.(1 … Finally, laryngotracheal stenosis occurs in approximately 1.7% of patients following tracheostomy, though

248. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49748/psn-pdf
     December 01, 2015 - The vasodilatation that occurs in the splanchnic bed leads to a lowering of mean arterial pressure and … If a patient develops a large fall in blood pressure, as occasionally occurs, I would give vasopressor

249. Unexplained Apnea Under Anesthesia | PSNet
     psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia
     December 01, 2005 - Prolonged apnea occurs more often in hyperventilated patients; neonates; elderly patients; patients with … Poor system design also makes errors difficult to intercept before injury occurs. … This problem also occurs with different doses of the same drug--the vials for at least three concentrations

250. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867359/psn-pdf
     December 18, 2024 - Processes for Infant Feeding Expressed breast milk being given to the wrong baby is a mistake that occurs … After an error occurs, healthcare teams should have an open discussion with the patient and family as … Healthcare team members should also be provided support after an error occurs.

251. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/72614/psn-pdf
     March 01, 2021 - Relatively rare, but still affecting thousands: Birth trauma occurs in approximately 7.4 out of every … shoulder dystocia (when the baby's shoulders cannot move past the mother's pelvis during delivery), which occurs … reported in an average of less than 1 percent of births; for example, maternal cerebrovascular accident occurs

252. Rapid Response Systems | PSNet
     psnet.ahrq.gov/primer/rapid-response-systems
     July 18, 2024 - standard cardiac arrest or "code blue" teams, which are summoned only after cardiopulmonary arrest occurs

253. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50389/psn-pdf
     September 25, 2019 - medical practice—rely on both of these processes, although the vast majority of our decision-making occurs … Diagnosis often occurs as a coproductive activity between persons in specific ecosystems, and the interactions

254. Rehearsing Team Care for Relatively Rare Obstetric Emergencies Leads to Improved Outcomes | PSNet
     psnet.ahrq.gov/innovation/rehearsing-team-care-relatively-rare-obstetric-emergencies-leads-improved-outcomes
     July 23, 2024 - Relatively rare, but still affecting thousands: Birth trauma occurs in approximately 7.4 out of every … shoulder dystocia (when the baby's shoulders cannot move past the mother's pelvis during delivery), which occurs … reported in an average of less than 1 percent of births; for example, maternal cerebrovascular accident occurs

255. Importance of Following Safe Practices for Infant Feeding and Handling Expressed Breast Milk | PSNet
     psnet.ahrq.gov/web-mm/importance-following-safe-practices-infant-feeding-and-handling-expressed-breast-milk
     January 31, 2024 - Processes for Infant Feeding Expressed breast milk being given to the wrong baby is a mistake that occurs … After an error occurs, healthcare teams should have an open discussion with the patient and family as … Healthcare team members should also be provided support after an error occurs.

256. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/840175/psn-pdf
     November 16, 2022 - Although this complication occurs more commonly on a mechanical mitral valve than on a mechanical aortic … recommended, in part because intravenous heparin therapy can be rapidly reversed with protamine if bleeding occurs

257. Hard to Swallow | PSNet
     psnet.ahrq.gov/web-mm/hard-swallow
     April 26, 2023 - This delay occurs primarily because medical records are voluminous and often organized in ways that promote … the electronic medical record (EMR) create safety mechanisms to assure that important communication occurs

258. Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules | PSNet
     psnet.ahrq.gov/web-mm/unintentional-ketamine-overdose-operating-room-mixing-ampules
     March 25, 2020 - Commentary By Christian Bohringer MD This incident describes a common type of adverse drug event that occurs … resuspended in different concentrations when they are drawn up from the ampule. 1,2   This type of event occurs

259. The Dropped "No" | PSNet
     psnet.ahrq.gov/web-mm/dropped-no
     October 30, 2019 - However, on dictation, the first word "No" was obscured by the dictation system click that occurs when … The primary error in this case was that the word "no" was obscured by the dictation system click that occurs

260. Breathe Easy: Safe Tracheostomy Management | PSNet
     psnet.ahrq.gov/web-mm/breathe-easy-safe-tracheostomy-management
     June 07, 2023 - Tracheo-esophageal fistula (TEF) occurs in approximately 1 in 1250 patients following tracheostomy.( … Finally, laryngotracheal stenosis occurs in approximately 1.7% of patients following tracheostomy, though