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Total Results: 1,040 records

Showing results for "type".

21. 25-Year summary of US malpractice claims for diagnostic errors 1986–2010: an analysis from the National Practitioner Data Bank. | PSNet
    psnet.ahrq.gov/issue/25-year-summary-us-malpractice-claims-diagnostic-errors-1986-2010-analysis-national
    July 17, 2019 - the outpatient setting —were both the most common and the most costly (in terms of total payments) type

22. Using incident reports to assess communication failures and patient outcomes. | PSNet
    psnet.ahrq.gov/issue/using-incident-reports-assess-communication-failures-and-patient-outcomes
    February 06, 2019 - Errors of purpose—a type of error in which the goals of the communication event remain unresolved, implying

23. Diagnostic overshadowing among groups experiencing health disparities. | PSNet
    psnet.ahrq.gov/issue/diagnostic-overshadowing-among-groups-experiencing-health-disparities
    February 10, 2021 - This alert highlights the presence of diagnostic overshadowing as a type of bias that is prone to affect

24. PowerPoint Presentation (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.344_slideshow.ppt
    April 01, 2015 - lumen within the middle layer Aortic dissections are classified by the area of aortic involvement Type … A: involving the ascending aorta Type B: all other dissections * Thrumurthy SG, Karthikesalingam … If undiagnosed and untreated, acute aortic dissection can have a very high mortality For untreated type … mortality is estimated to be 1%−2% per hour for the first 48 hours, with a 50% mortality by day 3 Type … A dissections, while 11% show no abnormality The comparable values in type B dissections were 56% and

25. Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan. | PSNet
    psnet.ahrq.gov/web-mm/be-picky-about-your-piccs-fragmented-care-and-poor-communication-discharge-leads-picc
    July 19, 2023 - The type of PICC line and French gauge (diameter in mm, e.g., 4 Fr. single lumen, or 5 Fr. dual lumen … using these devices should not lead health care providers to downplay the risks associated with this type … As with any central line, having clear documentation of the type of PICC line–i.e., single, dual, or … This type of hands-on, guided learning promotes confidence and enhances the patient’s ability to correctly

26. NHS Safety Thermometer Reports. | PSNet
    psnet.ahrq.gov/issue/nhs-safety-thermometer-report-patient-harms-and-harm-free-care-november-2014-november-2015
    July 08, 2021 - The NHS Safety Thermometer is no longer used as an official data type. 

27. Patient safety trends in 2023: an analysis of 287,997 serious events and incidents from the nation’s largest event reporting database. | PSNet
    psnet.ahrq.gov/issue/patient-safety-trends-2023-analysis-287997-serious-events-and-incidents-nations-largest-event
    July 24, 2024 - The most commonly reported event type were errors related to procedures, tests or treatments (accounting

28. Is that solution for IV or irrigation?: Fluid administration errors in the operating room. | PSNet
    psnet.ahrq.gov/web-mm/solution-iv-or-irrigation-fluid-administration-errors-operating-room
    January 29, 2021 - The Commentary By Christian Bohringer, MD These two incidents describe a common type of error that … This type of error has been reported previously with heparinized irrigation solutions. 1  Diluted sodium … Risk arising from these incidents Gentamicin is an aminoglycoside type antibiotic that is one of the … much as possible. 10 Implementing these changes to the operating room workflow will prevent this type … A designated pole for irrigation fluids can also help to prevent this type of error.

29. Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room | PSNet
    psnet.ahrq.gov/web-mm/saline-flush-leads-acute-paralysis-awake-patient-risks-improper-medication-labeling
    February 01, 2019 - Adverse drug events are the second most common type of error in healthcare. 2 It has long been known … one-third of these errors led to an observed harm, and 24% represented labeling errors, the most common type … Of these events, 276 were medication errors, of which the most common type was accidental administration … Color designation, or use of a pre-assigned color for each type of medication, can also facilitate prevention … Take Home Points Medication errors are common and labeling errors are the single most common type

30. High-alert medication administration and intravenous smart pumps: a descriptive analysis of clinical practice. | PSNet
    psnet.ahrq.gov/issue/high-alert-medication-administration-and-intravenous-smart-pumps-descriptive-analysis
    December 12, 2018 - multiple hospitals found that the majority of pump alerts are overridden by clinicians, regardless of the type

31. An examination of factors that predict the perioperative culture of safety. | PSNet
    psnet.ahrq.gov/issue/examination-factors-predict-perioperative-culture-safety
    May 12, 2021 - Prior research identified variability in perioperative safety culture by provider type and experience

32. Coping with errors in the operating room: intraoperative strategies, postoperative strategies, and sex differences. | PSNet
    psnet.ahrq.gov/issue/coping-errors-operating-room-intraoperative-strategies-postoperative-strategies-and-sex
    September 09, 2020 - This study evaluated the type and effectiveness of resident and faculty coping strategies following

33. High-risk medication errors: insight from the UK National Reporting and Learning System. | PSNet
    psnet.ahrq.gov/issue/high-risk-medication-errors-insight-uk-national-reporting-and-learning-system
    January 12, 2022 - Around half of errors for each type of medication occurred at administration . 97% of errors resulted

34. Medication errors in community pharmacies: evaluation of a standardized safety program. | PSNet
    psnet.ahrq.gov/issue/medication-errors-community-pharmacies-evaluation-standardized-safety-program
    June 29, 2022 - Event type, severity, medication class, and method of detection are described.

35. Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery. | PSNet
    psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesarean-delivery
    November 30, 2021 - this case). 2 Necrotizing soft tissue infections are commonly divided into several categories. 1,2 Type … Type II is a monomicrobial infection, classically due to either Group A streptococcus (most common) or … Type II cases may develop in young, healthy patients with no predisposing factors. 2 Type III includes … Type 2 processing is controlled, conscious, reflective, and analytic. … Type 1 (intuitive) thinking involves making a direct association between new information and a similar

36. Improving Diagnostic Safety and Quality | PSNet
    psnet.ahrq.gov/perspective/improving-diagnostic-safety-and-quality
    February 22, 2023 - 1 thinking); and one that is analytical and deliberative (type 2 thinking). 1 Cognitive biases and … heuristics (mental shortcuts that aid decision making) are examples of type 1 decision making during … A recent study examined heuristics related to type 1 processing in a primary care setting, noting that … Further, telling clinicians to slow down, ostensibly to switch from type 1 to type 2 thinking, may not … This type of holistic analysis is the logical effect of acknowledging that misdiagnosis is complex and

37. Direct oral anticoagulant-related medication incidents and pharmacists' interventions in hospital in-patients: evaluation using Reason's accident causation theory. | PSNet
    psnet.ahrq.gov/issue/direct-oral-anticoagulant-related-medication-incidents-and-pharmacists-interventions-hospital
    January 12, 2022 - This study assesses the frequency, type, and potential causality of DOAC-related medication errors and

38. The nature of reported safety events related to care coordination in the operating room setting in a tertiary academic center. | PSNet
    psnet.ahrq.gov/issue/nature-reported-safety-events-related-care-coordination-operating-room-setting-tertiary
    May 11, 2022 - In the perioperative setting of one hospital, insufficient handoffs were  the most common event type

39. The burden and risk factors for adverse drug events in older patients--a prospective cross-sectional study. | PSNet
    psnet.ahrq.gov/issue/burden-and-risk-factors-adverse-drug-events-older-patients-prospective-cross-sectional-study
    May 20, 2020 - South African emergency department and identified factors associated with risk for ADEs, such as the type

40. Learning collaboratives: insights and a new taxonomy from AHRQ's two decades of experience. | PSNet
    psnet.ahrq.gov/issue/learning-collaboratives-insights-and-new-taxonomy-ahrqs-two-decades-experience
    April 27, 2019 - AHRQ scientists proposes a taxonomy to describe collaboratives' distinct elements: innovation, or the type