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Showing results for "occurs".

  1. Just culture: the foundation of staff safety in the perioperative environment. | PSNet

    psnet.ahrq.gov/issue/just-culture-foundation-staff-safety-perioperative-environment
    June 09, 2021 - A just culture balances organizational and individual accountability when a medical error occurs

  2. Potentially inappropriate medication use and healthcare expenditures in the US community-dwelling elderly. | PSNet

    psnet.ahrq.gov/issue/potentially-inappropriate-medication-use-and-healthcare-expenditures-us-community-dwelling
    April 08, 2020 - cohort of noninstitutionalized elderly and found that inappropriate medication use in this population occurs

  3. The threat within: mitigating the risk of medical error. | PSNet

    psnet.ahrq.gov/issue/threat-within-mitigating-risk-medical-error
    July 15, 2020 - Despite efforts to protect patients, harm still occurs during the course of medical care.

  4. Grading recommendations for enhanced patient safety in sentinel event analysis: the recommendation improvement matrix. | PSNet

    psnet.ahrq.gov/issue/grading-recommendations-enhanced-patient-safety-sentinel-event-analysis-recommendation
    April 15, 2020 - The RIM consists of two elements—whether the intervention occurs before or after the event and whether

  5. The patients' perspective: hematological cancer patients' experiences of adverse events as part of care. | PSNet

    psnet.ahrq.gov/issue/patients-perspective-hematological-cancer-patients-experiences-adverse-events-part-care
    December 01, 2019 - When an error or adverse event occurs, patients and families want to be informed.

  6. Warm Handoff: Intervention | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/reports/engage/interventions/warmhandoff.html
    June 01, 2023 - A warm handoff is a transfer of care between two members of the health care team, where the handoff occurs

  7. Disclosure-and-resolution programs that include generous compensation offers may prompt a complex patient response. | PSNet

    psnet.ahrq.gov/issue/disclosure-and-resolution-programs-include-generous-compensation-offers-may-prompt-complex
    November 20, 2024 - Some institutions have implemented disclosure-and-resolution programs whenever an error occurs, in which

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33561/psn-pdf
    September 15, 2024 - reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle 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

  9. Primary Care Workforce | Agency for Healthcare Research and Quality

    www.ahrq.gov/ncepcr/reports/2025-annual-report/workforce.html
    August 01, 2025 - notes to produce predicted practice burnout scores to facilitate the prevention of burnout before it occurs … enables real-time reports using already collected EHR data to help predict and prevent burnout before it occurs

  10. Why do acute healthcare staff behave unprofessionally towards each other and how can these behaviours be reduced? A realist review. | PSNet

    psnet.ahrq.gov/issue/why-do-acute-healthcare-staff-behave-unprofessionally-towards-each-other-and-how-can-these
    July 24, 2024 - This narrative review characterized how, why, and under what circumstances unprofessional behavior occurs

  11. Doctors were alarmed: would I have my children have surgery here? | PSNet

    psnet.ahrq.gov/issue/doctors-were-alarmed-would-i-have-my-children-have-surgery-here
    February 19, 2020 - November 9, 2022 Misdiagnosis of thoracic aortic emergencies occurs frequently among

  12. On-Time Pressure Ulcer Assessment | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/assessment.html
    December 01, 2017 - Evaluate once a week and whenever a change occurs in the wound. … As healing occurs in dark-skinned persons, the new skin is pink and may never darken. … In full thickness wounds it occurs from the edges only.

  13. Exhibit 3.2. Grand Hospital Center | Agency for Healthcare Research and Quality

    www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit3-2.html
    November 01, 2014 - Communication about Lean: Ensure communication about changes resulting from project occurs.

  14. The effect of computerised decision support alerts tailored to intensive care on the administration of high-risk drug combinations, and their monitoring: a cluster randomised stepped-wedge trial. | PSNet

    psnet.ahrq.gov/issue/effect-computerised-decision-support-alerts-tailored-intensive-care-administration-high-risk
    October 18, 2023 - Alert fatigue occurs when clinical decision support systems (CDSS) produce numerous low-relevance alerts

  15. Puh-Assessment (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-assessment.pdf
    June 02, 2025 - Evaluate once a week and whenever a change occurs in the wound. … As healing occurs in dark-skinned persons, the new skin is pink and may never darken. 10. … In full thickness wounds it occurs from the edges only.

  16. Adverse Drug Events Occurring in U.S. Hospitals

    hcup-us.ahrq.gov/reports/infographics/adverse.jsp
    August 01, 2014 - Adverse Drug Events Occurring in U.S. Hospitals An official website of the Department of Health & Human Services Search All AHRQ Websites Careers Contact Us Espanol FAQs …

  17. Reducing the Risks of Wrong-Site Surgery: Safety Practices from The Joint Commission Center for Transforming Healthcare Project. | PSNet

    psnet.ahrq.gov/issue/reducing-risks-wrong-site-surgery-safety-practices-joint-commission-center-transforming
    October 19, 2016 - Wrong-site surgery is a never event , but still occurs at alarming rates.

  18. Serious Reportable Events in Healthcare—2011 Update. | PSNet

    psnet.ahrq.gov/issue/serious-reportable-events-healthcare-2011-update
    March 23, 2012 - When such an event occurs, many institutions mandate performance of a root cause analysis .

  19. Creating highly reliable health care: how reliability-enhancing work practices affect patient safety in hospitals. | PSNet

    psnet.ahrq.gov/issue/creating-highly-reliable-health-care-how-reliability-enhancing-work-practices-affect-patient
    January 12, 2022 - within high-risk industries that have adopted processes to detect and address failures before harm occurs

  20. Organizational learning: health care leaders need to design structures and processes that enhance collective learning. | PSNet

    psnet.ahrq.gov/issue/organizational-learning-health-care-leaders-need-design-structures-and-processes-enhance
    November 18, 2020 - The authors argue that true learning in health organizations occurs through a cyclical, dualistic, and
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