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Showing results for "occurs".

  1. Team cognition in handoffs: relating system factors, team cognition functions and outcomes in two handoff processes. | PSNet

    psnet.ahrq.gov/issue/team-cognition-handoffs-relating-system-factors-team-cognition-functions-and-outcomes-two
    February 16, 2022 - This qualitative study explores how team cognition occurs during care transitions and interprofessional

  2. Stakeholder perceptions of and attitudes towards problematic polypharmacy and prescribing cascades: a qualitative study. | PSNet

    psnet.ahrq.gov/issue/stakeholder-perceptions-and-attitudes-towards-problematic-polypharmacy-and-prescribing
    July 10, 2019 - An unintentional prescribing cascade occurs when a medication side effect is misinterpreted as a new

  3. Racial and ethnic harm in patient care is a patient safety issue. | PSNet

    psnet.ahrq.gov/issue/racial-and-ethnic-harm-patient-care-patient-safety-issue
    October 21, 2020 - ethnically marginalized patients, such as antiracism education and addressing harm promptly when it occurs

  4. Standardized assessment of medication reconciliation in post-acute care. | PSNet

    psnet.ahrq.gov/issue/standardized-assessment-medication-reconciliation-post-acute-care
    December 16, 2020 - Medication reconciliation (MR) occurs during transitions of care and is the process of reviewing a patient

  5. The effect of clinical experience on the error rate of emergency physicians. | PSNet

    psnet.ahrq.gov/issue/effect-clinical-experience-error-rate-emergency-physicians
    November 16, 2022 - often examined by conducting case reviews or root cause analyses when an undesired patient outcome occurs

  6. Ten years later, alarm fatigue is still a safety concern. | PSNet

    psnet.ahrq.gov/issue/ten-years-later-alarm-fatigue-still-safety-concern
    October 25, 2023 - Alarm (or alert) fatigue occurs when clinicians ignore alarms, usually due to the majority being invalid

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49581/psn-pdf
    March 21, 2009 - 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

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49628/psn-pdf
    June 01, 2011 - The most commonly cited preoperative risk is bleeding, which occurs in up to 3% of patients. … The highest risk of return to the operating room to control hemorrhage occurs one week postoperatively … The most common complication is postoperative bleeding, which occurs in less than 10% of patients.

  9. Methicillin-resistant Staphylococcus aureus disease in three communities. | PSNet

    psnet.ahrq.gov/issue/methicillin-resistant-staphylococcus-aureus-disease-three-communities
    July 03, 2014 - data indicates that acquisition of methicillin-resistant Staphylococcus aureus (MRSA) infection now occurs

  10. Nurses' safety motivation: examining predictors of nurses' willingness to report medication errors. | PSNet

    psnet.ahrq.gov/issue/nurses-safety-motivation-examining-predictors-nurses-willingness-report-medication-errors
    October 10, 2015 - that nurses are more willing to report medication errors if they perceive that feedback on errors occurs

  11. The medical emergency team system: a two hospital comparison. | PSNet

    psnet.ahrq.gov/issue/medical-emergency-team-system-two-hospital-comparison
    January 15, 2009 - further risk assess patients who may benefit from increased monitoring before a clinical deterioration occurs

  12. Current approaches to punitive action for medication errors by boards of pharmacy. | PSNet

    psnet.ahrq.gov/issue/current-approaches-punitive-action-medication-errors-boards-pharmacy
    May 26, 2011 - This occurs despite a consensus that such punitive measures are unlikely to improve patient safety.

  13. Prescription of teratogenic medications in United States ambulatory practices. | PSNet

    psnet.ahrq.gov/issue/prescription-teratogenic-medications-united-states-ambulatory-practices
    March 23, 2012 - prescribing patterns of potentially dangerous medications to nonpregnant young women, suggesting it occurs

  14. When doing wrong feels so right: normalization of deviance. | PSNet

    psnet.ahrq.gov/issue/when-doing-wrong-feels-so-right-normalization-deviance
    September 03, 2011 - This commentary explains the concept of normalization of deviance, which occurs when poor processes are

  15. “Those found responsible have been sacked”: some observations on the usefulness of error. | PSNet

    psnet.ahrq.gov/issue/those-found-responsible-have-been-sacked-some-observations-usefulness-error
    September 28, 2010 - improvement, but the concept isn’t universally accepted as an approach to determine the foci of how failure occurs

  16. Ethics in the pediatric emergency department: when mistakes happen: an approach to the process, evaluation, and response to medical errors. | PSNet

    psnet.ahrq.gov/issue/ethics-pediatric-emergency-department-when-mistakes-happen-approach-process-evaluation-and
    December 13, 2013 - The authors also explore the evidence on transparency in the ED when an error occurs and how to make

  17. Artificial lung ventilation tube connected to the patient in the bed (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/044-vap-prevention-essential.docx
    October 01, 2024 - If condensation occurs, drain away from patient.

  18. Implementation-Guide-Appendix-O (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/impl-guide/implementation-guide-appendix-o.docx
    June 02, 2025 - CAUTI Event Report Template When a catheter-associated urinary tract infection (CAUTI) occurs on your

  19. Blind Spot | PSNet

    psnet.ahrq.gov/web-mm/blind-spot
    July 30, 2020 - Specific ophthalmologic findings determine the diagnosis.( 5 ) AION occurs at the optic nerve head as … PION occurs anywhere posterior to the optic nerve head to the optic nerve chiasm. … Figure 2 ) with their eyes free from external pressure.( 6 ) These data clearly demonstrate that ION occurs … Cortical blindness is usually associated with embolic events or profound hypotension and most commonly occurs

  20. Methods Guide for Medical Test Reviews (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/pdf/methods-guidance-tests-bias_methods.pdf
    July 01, 2012 - Treatment paradox Occurs when treatment is started on the basis of the knowledge of the results of the … Disease progression bias Occurs when the index test is performed an unusually long time before the … Diagnostic review bias occurs when the results of the index test are known when the reference standard … In two or more observations of the same diagnostic study, intraobserver variability occurs when the … same person obtains different results, and interobserver variability occurs when two or more people
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