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Total Results: 4,038 records

Showing results for "occurs".

321. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866205/psn-pdf
     July 10, 2024 - If active resuscitation and transfusion are required, assessment of coagulation occurs in conjunction … Major vascular injury (e.g., left common iliac vein, inferior vena cava, or iliolumbar vein), occurs

322. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866055/psn-pdf
     May 29, 2024 - RSIs are the most common category of surgical never events.1 An RSI occurs when a needle, sponge, or … Surgical debrief occurs before the surgeon leaves the room.

323. Where errors occur in the preparation and administration of intravenous medicines: a systematic review and Bayesian analysis. | PSNet
     psnet.ahrq.gov/issue/where-errors-occur-preparation-and-administration-intravenous-medicines-systematic-review-and
     June 30, 2011 - Review Where errors occur in the preparation and administration of intravenous medicines: a systematic review and Bayesian analysis. Citation Text: McDowell SE, Mt-Isa S, Ashby D, et al. Where errors occur in the preparation and administration of intravenous medicines: a systematic rev…

324. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49667/psn-pdf
     October 01, 2012 - mental strengths and weaknesses of clinicians and how these affect whether or not a medication error occurs

325. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33579/psn-pdf
     September 15, 2024 - Attentional behavior is characterized by conscious thought, analysis, and planning, as occurs in active

326. In response to "Failure to Report" (March 2007) | PSNet
     psnet.ahrq.gov/perspective/response-failure-report-march-2007
     June 01, 2007 - When an error occurs in a situation where nurses may be manipulating a medication in a non-emergency

327. Spotlight Case [MONTH] 2003 (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.227_slideshow.ppt
     November 01, 2010 - Lack of direct or indirect communication between discharging and receiving team Direct communication occurs

328. Spotlight Case July 2008 (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.254_slideshow.ppt
     November 01, 2011 - Misses (2) Near misses may also be identified through active clinical monitoring Active monitoring occurs

329. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy. | PSNet
     psnet.ahrq.gov/web-mm/false-assumptions-result-missed-pneumothorax-after-bronchoscopy-transbronchial-biopsy
     March 15, 2023 - this symptom usually resolves within several days. 1 Post-bronchoscopy elevation in body temperature occurs … performed—which is often the reason for using navigational bronchoscopy, as in this case—pneumothorax occurs

330. Signout Fallout | PSNet
     psnet.ahrq.gov/web-mm/signout-fallout
     November 16, 2022 - Landrigan, MD, MPH As is often the case when a death occurs due to a preventable adverse event in hospital … Omissions of critical information or provision of outdated, erroneous information occurs frequently.(

331. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38360/psn-pdf
     March 18, 2010 - Medication errors occurring with the use of bar-code administration technology. March 18, 2010 PA-PSRS Patient Saf Advis. December 2008;5:122-126. https://psnet.ahrq.gov/issue/medication-errors-occurring-use-bar-code-administration-technology This article describes errors associated with bar coded medication admin…

332. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73067/psn-pdf
     March 24, 2021 - Changes in error patterns in unanticipated trauma deaths during 20 years: in pursuit of zero preventable deaths. March 24, 2021 LaGrone LN, McIntyre LK, Riggle A, et al. Changes in error patterns in unanticipated trauma deaths during 20 years: In pursuit of zero preventable deaths. J Trauma Acute Care Surg. 2020;89…

333. PowerPoint Presentation (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.365_slideshow.ppt
     January 01, 2016 - OJIN.Vol15No01Man04 11 Risk of Missed Nursing Care (2) Missed nursing care is an error of omission Occurs

334. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49539/psn-pdf
     June 01, 2007 - place; it does not absolve the clinician or the hospital from potential liability if a complication occurs

335. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60639/psn-pdf
     January 01, 2021 - Economic analysis of the prevalence and clinical and economic burden of medication error in England. July 1, 2020 Elliott RA, Camacho E, Jankovic D, et al. Economic analysis of the prevalence and clinical and economic burden of medication error in England. BMJ Qual Saf. 2021;30(2):96-105. doi:10.1136/bmjqs-2019-010…

336. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73181/psn-pdf
     April 28, 2021 - Critical incidents involving the medical emergency team: a 5-year retrospective assessment for healthcare improvement. April 28, 2021 Danielis M, Destrebecq A, Terzoni S, et al. Critical incidents involving the medical emergency team: a 5- year retrospective assessment for healthcare improvement. Dimens Crit Care …

337. Mechanical Prosthetic Valve Thrombosis with Thromboembolism. | PSNet
     psnet.ahrq.gov/web-mm/mechanical-prosthetic-valve-thrombosis-thromboembolism
     August 21, 2005 - 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

338. Treatment Challenges After Discharge | PSNet
     psnet.ahrq.gov/web-mm/treatment-challenges-after-discharge
     January 03, 2017 - Sadly, though, direct communication between physicians occurs only 3%–20% of the time, and the discharge … One such opportunity for harm occurs when test results are pending at the time of a care transition.

339. The Wrongful Resuscitation | PSNet
     psnet.ahrq.gov/web-mm/wrongful-resuscitation
     October 12, 2012 - Too often, the timing of discussions to clarify patient preferences only occurs in the last days of life … Rather, the more common error occurs when the physician has not written a DNR order because the patient's

340. Code Status Confusion | PSNet
     psnet.ahrq.gov/web-mm/code-status-confusion
     September 01, 2006 - If this occurs, hospital-based physicians must discuss treatment decisions with a surrogate decision-maker … If a cardiopulmonary arrest occurs, there is no opportunity to ask the patient whether she wants cardiopulmonary