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Total Results: over 10,000 records

Showing results for "occurs".

261. 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

262. Prevention of Falls in Community-Dwelling Older Adults: Clinical Summary of USPSTF Recommendation (pdf file)
     www.uspreventiveservicestaskforce.org/home/getfilebytoken/Xr36-Jkz_J5JpSwHojAkNx
     Benefit from vitamin D supplementation occurs by 12 months; the efficacy of treatment of shorter duration

263. 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

264. 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

265. 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

266. 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

267. “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

268. 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

269. 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

270. 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.

271. 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.

272. 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 .

273. Routine Goes Awry | PSNet
     psnet.ahrq.gov/web-mm/routine-goes-awry
     September 23, 2020 - 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.

274. Never Events | PSNet
     psnet.ahrq.gov/primer/never-events
     June 15, 2024 - other than as intended 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

275. 035-Importance-Mrsa-Prevention-Notes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/035-importance-mrsa-prevention-notes.docx
     October 01, 2024 - people in both community settings and healthcare facilities, but most of the morbidity and mortality occurs … Understanding how MRSA spreads and occurs is important for purposes of MRSA prevention. … MRSA infection occurs when MRSA on or in a patient’s body begins to cause invasive disease or adverse

276. Risks in the analogue and digitally-supported medication process and potential solutions to increase patient safety in the hospital: a mixed methods study. | PSNet
     psnet.ahrq.gov/issue/risks-analogue-and-digitally-supported-medication-process-and-potential-solutions-increase
     April 24, 2019 - In both processes, experts identified that the most critical risk of errors and harm occurs at admission

277. Suppl-2-User-Guide-To-Ocer 130129 (pdf file)
     effectivehealthcare.ahrq.gov/sites/default/files/suppl-2-user-guide-to-ocer_130129.pdf
     January 01, 2011 - risk for the entire population under different treatment conditions, then an average causal effect occurs … Investigators may not agree on a single DAG to represent a complex clinical question; when this occurs … Selection bias occurs when the risk for the outcome in the population being studied is different from … This bias occurs from estimating the average causal effect within “selected” stratum, then averaging … Selection bias occurs when participation in the study though volunteerism, design, adherence to treatment

278. Failure Modes and Effects Analysis Based on In Situ Simulations: A Methodology to Improve Understanding of Risks and Failures (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Davis_60.pdf
     April 07, 2008 - Introduction Catastrophic patient injury often occurs because of an unanticipated sequence of active … root cause analysis (RCA) and sentinel event analysis, which are carried out after an adverse event occurs … failures and to fix these problems to make the system more robust before an adverse event actually occurs … Detectability Is the area of failure readily known, or is it discovered only when a bad outcome occurs … Assessing patient safety risk before the injury occurs: An introduction to sociotechnical probabilistic

279. Serious Reportable Adverse Events in Health Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Kizer2.pdf
     December 01, 2000 - Of note, the frequency with which an event occurs was considered, but was not accepted as a criterion … Patient death or serious disability associated with intravascular air embolism that occurs while being … Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the … 346 Preventable describes an event that could have been anticipated and prepared against, but occurs … First, when an event occurs, it should be investigated to determine the underlying system problems and

280. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/grand-rounds-presentation-slides.pptx
     January 01, 2014 - CANDOR implementation process. 3 The Problem Despite major initiatives, patient harm from medical care occurs … want a health care organization, physician and/or care provider to be fully transparent when an error occurs … happened: This might be hard to answer at the time; but again, this is to stress that as the investigation occurs … necessarily be open with patients but also not to be honest with the organization when an adverse event occurs … Organizational leadership and support for the CANDOR process are key to ensure that it occurs. 31