Results

Total Results: 1,064 records

Showing results for "ultimately".

121. Shaping systems for better behavioral choices: lessons learned from a fatal medication error. | PSNet
     psnet.ahrq.gov/issue/shaping-systems-better-behavioral-choices-lessons-learned-fatal-medication-error
     February 12, 2020 - underlying problems, and for creating a " second victim " by disciplining the nurse (who was fired and ultimately

122. Engaging healthcare professionals and patient representatives in the development of a quality model for hospitals: a mixed-method study. | PSNet
     psnet.ahrq.gov/issue/engaging-healthcare-professionals-and-patient-representatives-development-quality-model
     October 23, 2013 - patient advisory council , staff, leadership, and clinicians participated in a multi-phase process which ultimately

123. Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events. | PSNet
     psnet.ahrq.gov/issue/improving-situation-awareness-reduce-unrecognized-clinical-deterioration-and-serious-safety
     December 02, 2014 - pediatric hospital that would improve situational awareness of clinically deteriorating patients and ultimately

124. The role of the medical emergency team in end-of-life care: a multicenter, prospective, observational study. | PSNet
     psnet.ahrq.gov/issue/role-medical-emergency-team-end-life-care-multicenter-prospective-observational-study
     July 13, 2010 - at seven hospitals in three countries, nearly one-third of patients seen by a rapid response team ultimately

125. Medical emergency team calls in the radiology department: patient characteristics and outcomes. | PSNet
     psnet.ahrq.gov/issue/medical-emergency-team-calls-radiology-department-patient-characteristics-and-outcomes
     July 06, 2011 - A case of an ultimately fatal adverse event that occurred while a patient was being transported from

126. The effect of executive walk rounds on nurse safety climate attitudes: a randomized trial of clinical units. | PSNet
     psnet.ahrq.gov/issue/effect-executive-walk-rounds-nurse-safety-climate-attitudes-randomized-trial-clinical-units
     June 16, 2011 - conclude that greater implementation of EWRs may serve as an important tool to improve safety culture and, ultimately

127. Closing the loop with ambulatory staff on safety reports. | PSNet
     psnet.ahrq.gov/issue/closing-loop-ambulatory-staff-safety-reports
     April 22, 2016 - At baseline, 50% of staff who requested feedback ultimately received it; after three years, the rate

128. Bundle interventions used to reduce prescribing and administration errors in hospitalized children: a systematic review. | PSNet
     psnet.ahrq.gov/issue/bundle-interventions-used-reduce-prescribing-and-administration-errors-hospitalized-children
     September 09, 2015 - The authors ultimately determined that the poor quality of existing literature precludes conclusions

129. A 38-year-old woman with fetal loss and hysterectomy. | PSNet
     psnet.ahrq.gov/issue/38-year-old-woman-fetal-loss-and-hysterectomy
     January 12, 2011 - details a seemingly routine full-term pregnancy that rapidly evolved into a course of complications, ultimately

130. Human Factors Engineering | PSNet
     psnet.ahrq.gov/primer/human-factors-engineering
     December 15, 2024 - Each of these safety hazards ultimately was attributed to a relatively simple yet overlooked problem … This workaround was deemed to be a substantial contributor to the ultimately fatal error.

131. Delayed time to defibrillation after in-hospital cardiac arrest. | PSNet
     psnet.ahrq.gov/issue/delayed-time-defibrillation-after-hospital-cardiac-arrest
     June 08, 2010 - Patients who received delays in treatment were ultimately found to have lower rates of survival after

132. Diagnostic inaccuracy of smartphone applications for melanoma detection. | PSNet
     psnet.ahrq.gov/issue/diagnostic-inaccuracy-smartphone-applications-melanoma-detection
     April 24, 2018 - The concern is that reliance on these dermatologic applications could delay diagnoses and ultimately

133. Medicare's decision to withhold payment for hospital errors: the devil is in the details. | PSNet
     psnet.ahrq.gov/issue/medicares-decision-withhold-payment-hospital-errors-devil-details
     March 13, 2013 - monitoring its effects, they applaud the efforts of this landmark policy and remain hopeful that it will ultimately

134. The Limits of Safety: Organizations, Accidents and Nuclear Weapons. | PSNet
     psnet.ahrq.gov/issue/limits-safety-organizations-accidents-and-nuclear-weapons
     July 28, 2013 - In fact, Sagan ultimately concludes that good fortune played a greater role than good design in the safety

135. The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age. | PSNet
     psnet.ahrq.gov/issue/digital-doctor-hope-hype-and-harm-dawn-medicines-computer-age
     January 09, 2018 - Ultimately, it paints a hopeful picture of where health care information technology may take us, making

136. Periodic Issue | PSNet
     psnet.ahrq.gov/periodic-issue/periodic-issue-426
     February 28, 2024 - Ultimately these experiences caused long-term harm to their mental health, decreased trust in healthcare … Ultimately these experiences caused long-term harm to their mental health, decreased trust in healthcare … The patient went into cardiac arrest and ultimately passed away.

137. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49499/psn-pdf
     December 02, 2020 - The patient ultimately received a diagnosis of left superficial femoral artery occlusion and underwent … Fortunately, the patient ultimately received the correct diagnosis and therapy with a desirable outcome

138. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33568/psn-pdf
     June 15, 2024 - The patient ultimately died of hypovolemic shock.  

139. From physician intent to the pharmacy label: prevalence and description of discrepancies from a cross-sectional evaluation of electronic prescriptions. | PSNet
     psnet.ahrq.gov/issue/physician-intent-pharmacy-label-prevalence-and-description-discrepancies-cross-sectional
     July 22, 2020 - prescribing physician's note with the order entered into the e-prescribing system and the medication ultimately

140. National study on the distribution, causes, and consequences of voluntarily reported medication errors between the ICU and non-ICU settings. | PSNet
     psnet.ahrq.gov/issue/national-study-distribution-causes-and-consequences-voluntarily-reported-medication-errors
     January 05, 2012 - An ultimately fatal medication error in an ICU patient is analyzed in this AHRQ WebM&M commentary .