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Total Results: 1,062 records

Showing results for "wrong".

141. Investigation of urology intraoperative events leading to root cause analysis at national VA medical centers. | PSNet
     psnet.ahrq.gov/issue/investigation-urology-intraoperative-events-leading-root-cause-analysis-national-va-medical
     June 02, 2021 - adverse events were improperly functioning equipment (e.g., broken scopes or smoking light cords), wrong … June 30, 2011 Incidence, patterns, and prevention of wrong-site surgery.

142. Thin Air | PSNet
     psnet.ahrq.gov/web-mm/thin-air
     March 01, 2006 - Review strategies for prevention of delivery of wrong gas to hospitalized patients. … with the appropriate color Christmas tree adapter, it is quite possible to attach the tubing to the wrong … A physical arrangement that precludes doing the wrong thing, like the gas-specific non-interchangeable … This helps to prevent the wrong regulator (in calibration and in color-code) from being attached to a … Consider the possibility that the wrong gas (or no gas) is being administered when a patient does not

143. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/854989/psn-pdf
     November 01, 2023 - medication administration (BCMA) technology reduces risk of many types of medication errors (e.g., wrong … drug, wrong patient, omission).

144. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60977/psn-pdf
     January 08, 2020 - Multiple Levels Involved in Prescribing the Wrong Medication September 30, 2020 Chin K, Chau V, Spero … Multiple Levels Involved in Prescribing the Wrong Medication. PSNet [internet]. 2020. … https://psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication The Case A 65-year-old … https://psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication The Commentary  … pended the wrong medication to the provider.

145. Understanding the facilitators and barriers to barcode medication administration by nursing staff using behavioural science frameworks. A mixed methods study. | PSNet
     psnet.ahrq.gov/issue/understanding-facilitators-and-barriers-barcode-medication-administration-nursing-staff-using
     August 28, 2024 - medication administration (BCMA) technology reduces risk of many types of medication errors (e.g., wrong … drug, wrong patient, omission ).

146. Methodological variations and their effects on reported medication administration error rates. | PSNet
     psnet.ahrq.gov/issue/methodological-variations-and-their-effects-reported-medication-administration-error-rates
     January 15, 2025 - For example, only 6 of 16 included studies considered administration of a drug at the wrong time to be … As delayed drug administration is relatively common, studies that did not include such wrong-time errors

147. From the randomized AMBORA trial to clinical practice: comparison of medication errors in oral antitumor therapy. | PSNet
     psnet.ahrq.gov/issue/randomized-ambora-trial-clinical-practice-comparison-medication-errors-oral-antitumor-therapy
     April 21, 2021 - June 19, 2013 Achieving the National Quality Forum's "Never Events": prevention of wrong … site, wrong procedure, and wrong patient operations.

148. Significant reduction in preanalytical errors for nonphlebotomy blood draws after implementation of a novel integrated specimen collection module. | PSNet
     psnet.ahrq.gov/issue/significant-reduction-preanalytical-errors-nonphlebotomy-blood-draws-after-implementation
     May 29, 2019 - Effect of restriction of the number of concurrently open records in an electronic health record on wrong-patient … Association of display of patient photographs in the electronic health record with wrong-patient … Development and implementation of a subcutaneous insulin pen label bar code scanning protocol to prevent wrong-patient

149. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33601/psn-pdf
     December 15, 2024 - that, while overall medication safety improved, new vulnerabilities emerged, including increases in wrong … patient, wrong medication, or wrongly timed orders. … challenges-electronic-health-records-and-diabetes-electronic-prescribing-implications-safety https://psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication … https://psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication https://www.ahrq.gov

150. Prevalence, contributory factors and severity of medication errors associated with direct-acting oral anticoagulants in adult patients: a systematic review and meta-analysis. | PSNet
     psnet.ahrq.gov/issue/prevalence-contributory-factors-and-severity-medication-errors-associated-direct-acting-oral
     December 22, 2021 - errors constituted the majority of error types, and common causes were active failures, including wrong … drug or wrong dose .

151. Intraoperative sentinel events in the era of surgical safety checklists: results of a national survey. | PSNet
     psnet.ahrq.gov/issue/intraoperative-sentinel-events-era-surgical-safety-checklists-results-national-survey
     August 04, 2021 - The most common adverse events reported were medication errors, wrong site/patient/procedure events, … Association of display of patient photographs in the electronic health record with wrong-patient

152. Rates of serious surgical errors in California and plans to prevent recurrence. | PSNet
     psnet.ahrq.gov/issue/rates-serious-surgical-errors-california-and-plans-prevent-recurrence
     March 09, 2022 - Retained foreign objects were the most commonly reported never event (66.2%), followed by wrong site … or wrong patient (15.5%), and surgical burns (7.7%).

153. Identification of common themes from never events data published by NHS England. | PSNet
     psnet.ahrq.gov/issue/identification-common-themes-never-events-data-published-nhs-england
     April 07, 2021 - 2020 in the National Health Services and categorized 51 common never events into four categories – wrong … site surgery (40% of events); retained foreign objects post-procedure (28%); wrong implant/prosthesis

154. Two words can soothe patients who have been harmed: we're sorry. | PSNet
     psnet.ahrq.gov/issue/two-words-can-soothe-patients-who-have-been-harmed-were-sorry
     July 26, 2017 - December 14, 2016 Misdiagnosis is more common than drug errors or wrong-site surgery. … March 7, 2007 The pain of wrong site surgery. … September 29, 2017 The right and wrong way to talk to patients about adverse events.

155. Fatal outcome after inadvertent injection of topical epinephrine. | PSNet
     psnet.ahrq.gov/issue/fatal-outcome-after-inadvertent-injection-topical-epinephrine
     May 07, 2018 - Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong … Site, Wrong Procedure and Wrong Person Surgery.

156. Discrepancy between emergency department admission diagnosis and hospital discharge diagnosis and its impact on length of stay, up-triage to the intensive care unit, and mortality. | PSNet
     psnet.ahrq.gov/issue/discrepancy-between-emergency-department-admission-diagnosis-and-hospital-discharge-diagnosis
     December 08, 2021 - perspective-taking on challenging premature closure after pediatric ICU physicians receive hand-off with the wrong … Related Resources The AHRQ Report on Diagnostic Errors in the Emergency Department: the wrong … answer to the wrong question.

157. From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case | PSNet
     psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premature-closure-and-anchoring-complicated-case
     October 02, 2013 - From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case … From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case. … From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case. … difficult to measure.( 2 ) The relatively long time lag between error and detection (compared with wrong-site … From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case.

158. Differences between methods of detecting medication errors: a secondary analysis of medication administration errors using incident reports, the Global Trigger Tool method, and observations. | PSNet
     psnet.ahrq.gov/issue/differences-between-methods-detecting-medication-errors-secondary-analysis-medication
     December 18, 2019 - For example, incident reports most commonly identified wrong dose and wrong time errors.

159. Application of Safety-II Principles | PSNet
     psnet.ahrq.gov/perspective/application-safety-ii-principles
     August 28, 2024 - patient safety is referred to as Safety-I , which defines safety as a condition where as few things go wrong … But it falls short because it emphasizes the few things that go wrong rather than seeking to understand … Rather than defining safety as the absence of adverse events, where as few things as possible go wrong … Labeling a review as an investigation may imply someone did something wrong. … For example, most people don't fall or get a wrong site surgery.

160. National Center for Patient Safety Falls Toolkit 2004. | PSNet
     psnet.ahrq.gov/issue/national-center-patient-safety-falls-toolkit-2004
     May 24, 2017 - March 14, 2016 Mix-up (wrong route of administration) of bladder irrigation with intravenous … April 6, 2011 Incidence, patterns, and prevention of wrong-site surgery. … &M Cases Too Hot For Comfort December 1, 2007 Mix-up (wrong