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Showing results for "occurs".

441. Detection of Safety Hazards | PSNet
     psnet.ahrq.gov/primer/detection-safety-hazards
     March 30, 2022 - probability that each error will be detected before causing harm, and the impact of the error if it actually occurs … ) and also requires performance of RCA under certain circumstances (such as when a  sentinel event  occurs

442. Monitoring-Programs-Rapid-Research-Appendix-C (xls file)
     effectivehealthcare.ahrq.gov/sites/default/files/related_files/monitoring-programs-rapid-research-appendix-c.xlsx
     October 08, 2025 - Communication of new, worsening, or resolved medication shortages occurs throughout the system and follows … Additionally, a medication shortage overview occurs as part of monthly formulary meetings. 5 Phases

443. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867652/psn-pdf
     February 26, 2025 - When an adverse event occurs in health care, it is critical to understand why and implement measures … For example, if a medication error occurs, healthcare organizations can complete a root cause analysis

444. Periodic Issue | PSNet
     psnet.ahrq.gov/periodic-issue/periodic-issue-473
     March 25, 2025 - Most medication safety research occurs in the inpatient setting, with less focus on ambulatory care. … Most medication safety research occurs in the inpatient setting, with less focus on ambulatory care.

445. Learning from Primary Care EHR Exemplars About HIT Safety - Final Report (pdf file)
     digital.ahrq.gov/sites/default/files/docs/citation/r21hs024327-ornstein-final-report-2018.pdf
     January 01, 2018 - Drug allergy interaction checking occurs during the entry of new medication. … Drug condition checking occurs for important interactions between drugs and selected conditions. … CPOE CDS Dose range checking occurs before medication orders are submitted. … Drug allergy interaction checking occurs during the entry of new medication. … checking occurs for important interactions between drugs and selectedconditions. 3).

446. Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected | PSNet
     psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect-unexpected
     September 25, 2024 - Patient death or serious injury associated with intravascular air embolism that occurs while being cared … in children can be considered but has not been recommended. 3 , 5 , 15     If an adverse event occurs … Once a complication occurs, escalation of care requires three fundamental communication steps as identified

447. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33582/psn-pdf
     September 15, 2024 - probability that each error will be detected before causing harm, and the impact of the error if it actually occurs … FMEA) and also requires performance of RCA under certain circumstances (such as when a sentinel event occurs

448. Failure Mode and Effects Analysis | Digital Healthcare Research
     digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/fmea-analysis
     January 01, 2023 - Determine what the patient would experience if the failure occurs. 6.

449. Slide 1
     effectivehealthcare.ahrq.gov/sites/default/files/exposure-definition-and-measurement_chapter-4.pptx
     January 01, 2013 - The second column (D–F) shows scenarios where the exposure of interest occurs at a single point in time … Any medication use that occurs during the induction and latent periods should not be included in the … Differential misclassification occurs when the error in the exposure measurement is dependent on the … Nondifferential measurement error occurs when there are errors in the measurement of exposure that are … Immortal time bias occurs when person-time is inappropriately assigned to an exposure category.

450. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33844/psn-pdf
     October 01, 2017 - , and norovirus.(6) Despite how risky health care worker presenteeism is for patients, it commonly occurs … and Knowledge Like many threats to patient safety, the reasons why health care worker presenteeism occurs

451. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49700/psn-pdf
     February 01, 2014 - is not associated with increased risk of sudden death or all-cause mortality, particularly when it occurs … In the case of new-onset NSVT, NSVT that is increasing in frequency or duration, or NSVT that occurs

452. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/865418/psn-pdf
     March 27, 2024 - is full integration between all the departments.8 How to Respond to a Cyberattack When an attack occurs … keep everyone informed of potential or current patient safety issues.11 When a patient-safety event occurs

453. Task Force Issues Final Recommendation Statement on Folic Acid Supplementation to Prevent Neural Tube Defects: Taking folic acid before and during early pregnancy helps prevent neural tube defects (pdf file)
     www.uspreventiveservicestaskforce.org/uspstf/sites/default/files/file/supporting_documents/folic-acid-suppl-final-rec-bulletin.pdf
     August 01, 2023 - This occurs early in pregnancy, often before a person knows they are pregnant.

454. Procedural Mishap: Learning Curve? | PSNet
     psnet.ahrq.gov/web-mm/procedural-mishap-learning-curve
     April 28, 2021 - Prospective studies have reported that injury to the bowel or major vessels during laparoscopic procedures occurs … major vessels are the distal aorta and the right common iliac artery (RCIA).( 7 ) This injury pattern occurs

455. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/72693/psn-pdf
     January 29, 2021 - Commentary By Christian Bohringer MD This incident describes a common type of adverse drug event that occurs … resuspended in different concentrations when they are drawn up from the ampule.1,2  This type of event occurs

456. Spotlight (pdf file)
     psnet.ahrq.gov/sites/default/files/2022-08/final_spotlight_case_mesenteric_ischemia_08.05.2022.pdf
     January 01, 2022 - Robles, MD, and Garth Utter, MD, MSc 9 BACKGROUND 10 Background (1) • Mesenteric ischemia occurs … Background (2) • Major causes of mesenteric ischemia – Acute mesenteric, or intestinal, ischemia occurs … Obstruction of the venous mesenteric outflow occurs as a result of venous thrombosis of the superior

457. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/837963/psn-pdf
     August 31, 2022 - Anamaria Robles, MD, and Garth Utter, MD, MSc Background: Mesenteric Ischemia Mesenteric ischemia occurs … Acute mesenteric, or intestinal, ischemia occurs when perfusion abruptly decreases, with or without … https://psnet.ahrq.gov//#1 Obstruction of the venous mesenteric outflow occurs as a result of venous

458. Update Topic CER 31 Clostridium difficile NSD FINAL (pdf file)
     effectivehealthcare.ahrq.gov/sites/default/files/c-diff-infections-nomination-140925.pdf
     February 19, 2014 - . § Recurrence occurs in up to 20% of people affected by C. difficile, either because the initial

459. Enhancing Fulfillment Data in Community Practices for Clinical Care and Research - 2011 | Digital Healthcare Research
     digital.ahrq.gov/ahrq-funded-projects/enhancing-fulfillment-data-community-practices-clinical-care-and-research/annual-summary/2011
     January 01, 2011 - The focus of this study strives to extend beyond what occurs at the pharmacy level to include additional

460. Section1 5 (pdf file)
     hcup-us.ahrq.gov/reports/factsandfigures/2007/pdfs/section1_5.pdf
     January 01, 2007 - This high rate of hospital stays occurs because nearly all births occur in the hospital and some infants