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Total Results: 1,062 records

Showing results for "wrong".

101. A multicenter collaborative effort to reduce preventable patient harm due to retained surgical items. | PSNet
     psnet.ahrq.gov/issue/multicenter-collaborative-effort-reduce-preventable-patient-harm-due-retained-surgical-items
     March 20, 2019 - October 5, 2022 A contemporary analysis of closed claims related to wrong site surgery … January 15, 2025 Patient Safety Primers Wrong-Site, Wrong-Procedure … , and Wrong-Patient Surgery December 15, 2024 Patient falls in the operating

102. Communication failures contributing to patient injury in anaesthesia malpractice claims. | PSNet
     psnet.ahrq.gov/issue/communication-failures-contributing-patient-injury-anaesthesia-malpractice-claims
     August 04, 2021 - Anesthesia for Emergency Cesarean Delivery June 28, 2023 Insurance claims for wrong-side … , wrong-organ, wrong-procedure, or wrong-person surgical errors: a retrospective study for 10 years.

103. So many ways to be wrong: completeness and accuracy in a prospective study of OR-to-ICU handoff standardization. | PSNet
     psnet.ahrq.gov/issue/so-many-ways-be-wrong-completeness-and-accuracy-prospective-study-or-icu-handoff
     April 28, 2021 - Study So many ways to be wrong: completeness and accuracy in a prospective study … So many ways to be wrong: completeness and accuracy in a prospective study of OR-to-ICU handoff standardization … So many ways to be wrong: completeness and accuracy in a prospective study of OR-to-ICU handoff standardization

104. Surgeon perception and attitude towards the moral imperative of institutionally addressing second-victim syndrome in surgery. | PSNet
     psnet.ahrq.gov/issue/surgeon-perception-and-attitude-towards-moral-imperative-institutionally-addressing-second
     March 24, 2019 - March 8, 2023 Insurance claims for wrong-side, wrong-organ, wrong-procedure, or wrong-person

105. Compliance with and barriers to implementing the surgical safety checklist: a mixed-methods study. | PSNet
     psnet.ahrq.gov/issue/compliance-and-barriers-implementing-surgical-safety-checklist-mixed-methods-study
     October 06, 2021 - August 17, 2022 Using performance improvement to enhance time-out compliance and prevent wrong-site … More Related Resources Patient Safety Primers Wrong-Site … , Wrong-Procedure, and Wrong-Patient Surgery December 15, 2024 Improving team

106. Systematic workup of transfusion reactions reveals passive co-reporting of handling errors. | PSNet
     psnet.ahrq.gov/issue/systematic-workup-transfusion-reactions-reveals-passive-co-reporting-handling-errors
     December 21, 2016 - Related Resources Serious hazards of transfusion: evaluating the dangers of a wrong … October 5, 2022 Adding automation and independent dual verification to reduce wrong blood … 2022 Machine learning models outperform manual result review for the identification of wrong … December 16, 2020 WebM&M Cases “This is the wrong patient's … : Evaluating a Near-Miss Wrong Transfusion Event January 29, 2020 Safety incident

107. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33585/psn-pdf
     March 15, 2025 - harm patients generally involve overexposure to radiation, which can cause direct toxicity; cases of wrong-patient … and wrong-site errors have also been reported. … 2010 news investigation found that many cases in which patients experienced serious harm were due to wrong … For example, since many imaging tests are performed in https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery

108. Right Kind of Wrong: Why Learning to Fail can Teach us to Thrive. | PSNet
     psnet.ahrq.gov/issue/right-kind-wrong-why-learning-fail-can-teach-us-thrive
     February 06, 2018 - Book/Report Right Kind of Wrong: Why Learning to Fail can Teach us to Thrive. … Citation Text: Right Kind of Wrong: Why Learning to Fail can Teach us to Thrive. Edmondson A. … Copy URL Cite Citation Citation Text: Right Kind of Wrong

109. The rise of human factors: optimising performance of individuals and teams to improve patients' outcomes. | PSNet
     psnet.ahrq.gov/issue/rise-human-factors-optimising-performance-individuals-and-teams-improve-patients-outcomes
     July 10, 2024 - September 28, 2022 Wrong administration route of medications in the domestic setting: … November 14, 2011 When surgery goes wrong: weighing up the risks. … June 9, 2011 Information needs in operating room teams: what is right, what is wrong,

110. Swiss Cheese Model | PSNet
     psnet.ahrq.gov/glossary/swiss-cheese-model
     September 13, 2021 - For example, if the hazard were wrong-site surgery, slices of the cheese might include conventions for … For some serious events (e.g., operating on the wrong site or wrong person), even though the holes will

111. Mother's Milk, but Whose Mother? | PSNet
     psnet.ahrq.gov/web-mm/mothers-milk-whose-mother
     November 15, 2023 - In other words, they confirmed that the patient had unquestionably received 15 mL of the wrong human … infectious diseases consult subsequently counseled the family regarding potential risks from using the wrong … These failures resulted in breast milk being fed to the wrong infant. … did not prevent them from occurring.( 6 ) Risk of Exposure to and Disease Transmission from the Wrong … Breast Milk In this case, the 8-week-old relatively healthy infant who ingested 15 mL of the wrong

112. Prevalence and nature of medication administration errors in health care settings: a systematic review of direct observational evidence. | PSNet
     psnet.ahrq.gov/issue/prevalence-and-nature-medication-administration-errors-health-care-settings-systematic-review
     April 01, 2015 - the inpatient setting, although the majority of these errors appear to be administering drugs at the wrong … time rather than administering the wrong dose or wrong medication entirely.

113. Unexplained Apnea Under Anesthesia | PSNet
     psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia
     December 01, 2005 - room Patient Safety Objectives State the prevalence of medication errors List the causes of wrong … maintaining cardiovascular and respiratory functions, clinicians should attempt to ascertain whether a wrong … injuries due to drugs were the most frequent cause of procedure-related malpractice claims.( 7 ) Wrong … The “wrong drug” problem in anesthesia: an analysis of 2000 incident reports. … March 2, 2011 Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events

114. The wicked problem of patient misidentification: how could the technological revolution help address patient safety? | PSNet
     psnet.ahrq.gov/issue/wicked-problem-patient-misidentification-how-could-technological-revolution-help-address
     July 10, 2024 - October 8, 2016 Electronic patient identification for sample labeling reduces wrong blood … 2023 Machine learning models outperform manual result review for the identification of wrong … Effect of restriction of the number of concurrently open records in an electronic health record on wrong-patient

115. Patient falls in the operating room: why is this still a problem in 2024? | PSNet
     psnet.ahrq.gov/issue/patient-falls-operating-room-why-still-problem-2024
     May 08, 2024 - More Related Resources Patient Safety Primers Wrong-Site … , Wrong-Procedure, and Wrong-Patient Surgery December 15, 2024 Grading recommendations

116. The Anesthesia Patient Safety Foundation at 25: a pioneering success in safety, 25th anniversary provokes reflection, anticipation. | PSNet
     psnet.ahrq.gov/issue/anesthesia-patient-safety-foundation-25-pioneering-success-safety-25th-anniversary-provokes
     January 01, 2015 - September 29, 2017 View More Related Resources Insurance claims for wrong-side … , wrong-organ, wrong-procedure, or wrong-person surgical errors: a retrospective study for 10 years.

117. The deterrent effect of tort law: evidence from medical malpractice reform. | PSNet
     psnet.ahrq.gov/issue/deterrent-effect-tort-law-evidence-medical-malpractice-reform
     July 26, 2017 - July 14, 2021 View More Related Resources Insurance claims for wrong-side … , wrong-organ, wrong-procedure, or wrong-person surgical errors: a retrospective study for 10 years.

118. E-prescribing: E for error? | PSNet
     psnet.ahrq.gov/web-mm/e-prescribing-e-error
     February 03, 2021 - However, electronic systems have a more difficult time addressing certain safety issues, such as wrong … patient or wrong diagnosis. … In addition to system functionalities that could have prevented dispensing the wrong medication to the … wrong patient, many provider-focused interventions may be necessary to optimize medication safety. … the wrong patient, especially when a prescription is canceled or changed.

119. Medication errors and error chains involving high-alert medications in a paediatric hospital setting: a qualitative analysis of self-reported medication safety incidents. | PSNet
     psnet.ahrq.gov/issue/medication-errors-and-error-chains-involving-high-alert-medications-paediatric-hospital
     March 27, 2024 - One-quarter of incidents included two to four errors, and wrong dose or omission were the most common … Systemic defenses are required to reduce wrong dose, omission, and documentation errors.

120. Self-reported violations during medication administration in two paediatric hospitals. | PSNet
     psnet.ahrq.gov/issue/self-reported-violations-during-medication-administration-two-paediatric-hospitals
     December 01, 2010 - March 17, 2010 Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events