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Total Results: 4,038 records

Showing results for "occurs".

261. Spotlight (pdf file)
     psnet.ahrq.gov/sites/default/files/2022-10/spotlight_case_missed_pneumothorax_10.09.2022_-_final.pdf
     January 01, 2022 - – Post-bronchoscopy elevation in body temperature occurs commonly (up to 33% of cases), but typically … performed—which is often the reason for using navigational bronchoscopy, as in this case—pneumothorax occurs

262. Preventing Complications during Aneurysm Clipping – the Role of Neuromonitoring. | PSNet
     psnet.ahrq.gov/web-mm/preventing-complications-during-aneurysm-clipping-role-neuromonitoring
     July 02, 2011 - of patients and caused severe neurological outcome in the survivors. 11,12 Aneurysmal rebleeding occurs … New post-operative stroke occurs in up to 11% of patients undergoing aneurysm clipping. 14 To mitigate

263. Rethinking Root Cause Analysis | PSNet
     psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
     August 21, 2016 - 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.

264. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49560/psn-pdf
     April 01, 2008 - Too often, the timing of discussions to clarify patient preferences only occurs in the last days of … Rather, the more common error occurs when the physician has not written a DNR order because the patient's

265. An Easily Forgotten Tube | PSNet
     psnet.ahrq.gov/web-mm/easily-forgotten-tube
     June 01, 2016 - FMS is unsuitable for spinal cord injury patients due to the high risk of autonomic dysreflexia that occurs … persistent rectal pain, rectal bleeding, and abdominal distention.( 8 ) If any suspected adverse event occurs

266. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33711/psn-pdf
     May 01, 2011 - surveillance of all caregivers by individuals specifically educated on the second victim phenomenon occurs … experienced by clinicians after unanticipated clinical events or medical errors.(22) When a serious event occurs

267. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49637/psn-pdf
     October 01, 2011 - However, on dictation, the first word "No" was obscured by the dictation system click that occurs when … primary error in this case was that the word "no" was obscured by the dictation system click that occurs

268. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49466/psn-pdf
     October 14, 2004 - This delay occurs primarily because medical records are voluminous and often organized in ways that … the electronic medical record (EMR) create safety mechanisms to assure that important communication occurs

269. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33772/psn-pdf
     September 01, 2014 - The first occurs when a patient has an unnecessary procedure, such as back surgery or cardiac procedure … It addresses the so-called moral hazard that occurs when people use more health care services because

270. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/851971/psn-pdf
     July 31, 2023 - eats indiscriminately whatever it finds.1 Pica is often associated with iron deficiency and therefore occurs … Intentional foreign body ingestion occurs most often in children under three years of age. … In adults, repeated intentional ingestion of metal objects usually occurs in patients with borderline

271. Analysis of risk factors for patient safety events occurring in the emergency department. | PSNet
     psnet.ahrq.gov/issue/analysis-risk-factors-patient-safety-events-occurring-emergency-department
     January 26, 2022 - Study Analysis of risk factors for patient safety events occurring in the emergency department. Citation Text: Alsabri M, Boudi Z, Zoubeidi T, et al. Analysis of risk factors for patient safety events occurring in the emergency department. J Patient Saf. 2022;18(1):e124-e135. doi:10.1097…

272. Getting the Diagnosis Both Right and Wrong | PSNet
     psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong
     May 29, 2024 - 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

273. Key Issues in Developing a Successful Hospital Safety Program | PSNet
     psnet.ahrq.gov/perspective/key-issues-developing-successful-hospital-safety-program
     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

274. In Conversation with...Allan Frankel, MD | PSNet
     psnet.ahrq.gov/perspective/conversation-withallan-frankel-md
     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

275. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33563/psn-pdf
     September 16, 2024 - on interprofessional relationships and other local circumstances, and thus changing safety culture occurs

276. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/862601/psn-pdf
     February 14, 2024 - Why simulation matters: a systematic review on medical errors occurring during simulated health care. February 14, 2024 Bokka L, Ciuffo F, Clapper TC. Why simulation matters: a systematic review on medical errors occurring during simulated health care. J Patient Saf. 2024;20(2):110-118. doi:10.1097/pts.000000000000…

277. The Second Victim Phenomenon: A Harsh Reality of Health Care Professions | PSNet
     psnet.ahrq.gov/perspective/second-victim-phenomenon-harsh-reality-health-care-professions
     November 13, 2024 - surveillance of all caregivers by individuals specifically educated on the second victim phenomenon occurs … experienced by clinicians after unanticipated clinical events or medical errors.( 22 ) When a serious event occurs

278. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/48053/psn-pdf
     July 17, 2019 - Review of medication errors that are new or likely to occur more frequently with electronic medication management systems. July 17, 2019 Van de Vreede M, McGrath A, de Clifford J. Review of medication errors that are new or likely to occur more frequently with electronic medication management systems. Aust Health …

279. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60159/psn-pdf
     March 25, 2020 - Root cause analyses of reported adverse events occurring during gastrointestinal scope and tube placement procedures in the Veterans Health Association. March 25, 2020 Soncrant C, Mills PD, Neily J, et al. Root cause analyses of reported adverse events occurring during gastrointestinal scope and tube placement pro…

280. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74086/psn-pdf
     November 17, 2021 - Review of reported adverse events occurring among the homeless veteran population in the Veterans Health Administration. November 17, 2021 Soncrant C, Mills PD, Pendley Louis RP, et al. Review of reported adverse events occurring among the homeless veteran population in the Veterans Health Administration. J Patien…