-
digital.ahrq.gov/sites/default/files/ahrq-dhr-2023-year-in-review.pdf
January 01, 2023 - Wrong patient orders can harm patients. … Wrong patient orders can
relate to medications, lab and imaging tests, procedures, nursing orders, … “Orders placed on the wrong patient should be a ‘never event,’ as in it should
never happen,” said … -
Wrong patient orders were identified by using the Wrong-Patient Retract-and-
Reorder Measure (WP-RAR … ), a validated, reliable, and automated method
for identifying wrong-patient orders developed by Dr
-
digital.ahrq.gov/sites/default/files/docs/citation/r01hs023837-gurses-final-report-2021.pdf
January 01, 2021 - (3) Why would something go wrong with T3? (4) What can be done to address those issues? … During the first step of the PRA, participants were asked to come up with issues that could go wrong … Participants were asked, for each top-rated vulnerability, why
would something go wrong with T3, and … Possible safety consequences
• Patient care is based on
wrong information
• Inappropriate care
• … Wrong doses (medication,etc.) • Highlight in red the unidentified information
elements such ass name
-
digital.ahrq.gov/sites/default/files/docs/resource/PCC_Adams_Q2_PHPCounselingActivation.pdf
June 16, 2021 - Group Answer(s)
Counseling
message
Activation
Message
Follow-up Questions
Med Safety med rec wrong
-
digital.ahrq.gov/ahrq-funded-projects/power-patient-design-and-test-closed-loop-interactive-it-geriatric-heart
January 01, 2023 - changes in status, misinterpret or misevaluate symptoms, do not take responsive action, or choose the wrong
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digital.ahrq.gov/sites/default/files/docs/publication/BarrierstoMeaningfulUseAppendixF.pdf
October 31, 2013 - First of all, everyone should know there is no right or wrong answer. … Remember, there is no right or wrong answer. We just want to hear what you have to say.
-
digital.ahrq.gov/sites/default/files/docs/publication/uc1hs016160-sakuda-final-report-2009.pdf
January 01, 2009 - • If a PCP is not identified, hospitals send patient records to the wrong place. … cannot get to care (ED, CHC), cannot get back home X
Don’t understand why referred to specialist/wrong … CHC gives priority to patients needing f/u from tertiary centers X
Incorrect information shared; wrong … discuss care to be provided X
Needs information written down X
Problem in telling doctor what’s wrong … losing records, floods
X
Inconvenient, staff lined up to use the computer X
Computer can transmit wrong
-
digital.ahrq.gov/ahrq-funded-projects/home-heart-failure-hf-care-comparing-patient-driven-technology-models
January 01, 2023 - Vincent Hospital (SVH) in Billings, Mont., and if something is wrong -- if his readings are outside normal
-
digital.ahrq.gov/sites/default/files/docs/citation/r21hs024350-wernz-final-report-2018.pdf
January 01, 2018 - Issue Entering Order Placement of medication order disrupted 3
Administration Includes: delay, wrong … dose, wrong medication, and
medication tracking 8
Patient Registration Issue caused patient registration
-
digital.ahrq.gov/sites/default/files/docs/page/ahrq-dhr-2021-year-in-review.pdf
January 01, 2021 - and Wrong-
Patient Errors With Indication Alerts
in CPOE Systems
Poster: Implementation of
Medication … Alerts to Reduce Wrong-
Drug and Wrong-Patient Errors in
CPOE Systems
R E S E A R C H D I S S E M … 80EF-D1E7CDE2D2B0&session_date=Monday,%20Nov%2001,%202021
https://digital.ahrq.gov/ahrq-funded-projects/preventing-wrong-drug-and-wrong-patient-errors-indication-alerts-cpoe-systems … https://digital.ahrq.gov/ahrq-funded-projects/preventing-wrong-drug-and-wrong-patient-errors-indication-alerts-cpoe-systems … https://digital.ahrq.gov/ahrq-funded-projects/preventing-wrong-drug-and-wrong-patient-errors-indication-alerts-cpoe-systems
-
digital.ahrq.gov/sites/default/files/docs/publication/Dorr_Care_Mgmt_Disc_Guide.pdf
November 18, 2008 - There are no right or wrong answers (please stress this).
-
digital.ahrq.gov/sites/default/files/docs/page/Estrin%20connecting%20for%20health.ppt
June 01, 2006 - Initiative
Once the Regional Data Exchange Agreement Draft was completed we thought we could relax …
WRONG
-
digital.ahrq.gov/sites/default/files/docs/page/2006Estrin_Ftrd_051211comp.pdf
June 01, 2006 - Initiative
Once the Regional Data Exchange Agreement Draft
was completed we thought we could relax …
• WRONG
-
digital.ahrq.gov/sites/default/files/docs/publication/BarrierstoMeaningfulUseAppendixD.pdf
October 31, 2013 - First of all, everyone should know there is no right or wrong answer. … Remember, there is no right or wrong answer. We just want to hear what you have to say.
-
digital.ahrq.gov/sites/default/files/docs/survey/care-management-discussion-guide.pdf
November 18, 2008 - There are no right or wrong answers (please stress this).
-
digital.ahrq.gov/sites/default/files/docs/publication/uc1hs015270-hayden-final-report-2008.pdf
January 01, 2008 - “We’re waiting for a screen to come up and tell us ‘Wait this it wrong; this is the wrong
patient.’ … Assuming the nurse even knows that s/he gave the wrong
medication, these types of errors tend to be … that the software would alert a
nurse about a potential error before s/he actually administered the wrong … • Compound verification wrong med – the nurse is about to administer a compounded
medication that
-
digital.ahrq.gov/sites/default/files/docs/publication/BarrierstoMeaningfulUseAppendixE.pdf
October 31, 2013 - First of all, everyone should know there is no right or wrong answer. … Remember, there is no right or wrong answer. We just want to hear what you have to say.
-
digital.ahrq.gov/sites/default/files/docs/HOW%20HEALTH%20IT%20CAN%20REDUCE%20UNNECESSARY%20REHOSPITALIZATION.pdf
June 16, 2021 - And there is lots of scripts that we go
through, and if they get that wrong, and to try to teach them … of patients who had, for example,
a stress test scheduled after discharge, and they would go to the wrong … And
there was one case where they missed the appointment and finally, you know - they went to the wrong … JENCKS: And if anything, they are in the wrong direction.
SPEAKER: Yes. Yes.
-
digital.ahrq.gov/sites/default/files/docs/citation/AppendixE_HIT_Hazard_Manager_Beta_Test.pdf
June 16, 2021 - Confusing information display (1)
• Incorrect patient information (5)
• Information linked to the wrong … information display (3)
• Mismatch between HIT function and clinical reality (2)
• Information linked to wrong
-
digital.ahrq.gov/sites/default/files/docs/improving-hit-safety-slides-020717.pdf
February 07, 2017 - • ~5 million errors per year are tied to wrong medications;
1 in 4 medication errors involves a … entries, typed notes
• Real-word errors (i.e., the word is spelled correctly but
is contextually wrong
-
digital.ahrq.gov/sites/default/files/ahrq-dhr-2023-year-in-review-at-a-glance.pdf
January 01, 2023 - Investment: $1,577,033
Patient photos displayed in the electronic health
record significantly reduce wrong-patient