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Total Results: 4,259 records

Showing results for "wrong".

181. Factors contributing to preventing operating room "never events": a machine learning analysis. | PSNet
     psnet.ahrq.gov/issue/factors-contributing-preventing-operating-room-never-events-machine-learning-analysis
     July 26, 2023 - machine learning, this study identified 24 contributing factors to two types of surgical never events - wrong … July 27, 2023 A contemporary analysis of closed claims related to wrong site surgery. … October 20, 2021 Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient … April 7, 2021 Incidence of wrong-site surgery list errors for a 2-year period in a single … Room Quality and Safety Professionals Surgery Retained Surgical Instruments and Sponges Wrong

182. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74077/psn-pdf
     November 17, 2021 - Factors associated with wrong blood in tube errors: an international case series - The BEST collaborative … https://psnet.ahrq.gov/issue/factors-associated-wrong-blood-tube-errors-international-case-series-best … - collaborative-study Wrong blood in tube (WBIT) errors can be classified as intended patient drawn … /wrong label applied or wrong patient/intended label applied. … https://psnet.ahrq.gov/web-mm/right-patient-wrong-sample https://psnet.ahrq.gov/issue/electronic-patient-identification-sample-labeling-reduces-wrong-blood-tube-errors

183. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73429/psn-pdf
     June 23, 2021 - Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient Settings. … https://psnet.ahrq.gov/issue/wrong-site-surgery-wrong-patient-invasive-procedures-outpatient-settings … Wrong site/wrong patent surgery is a persistent healthcare never event. … Service (NHS) reporting data to identify how ambulatory patient identification errors contribute to wrong … https://psnet.ahrq.gov/issue/wrong-site-surgery-wrong-patient-invasive-procedures-outpatient-settings

184. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/838251/psn-pdf
     October 05, 2022 - Serious hazards of transfusion: evaluating the dangers of a wrong patient autologous salvaged blood … Serious hazards of transfusion: evaluating the dangers of a wrong patient autologous salvaged blood … https://psnet.ahrq.gov/issue/serious-hazards-transfusion-evaluating-dangers-wrong-patient-autologous- … salvaged-blood Wrong-patient transfusion errors can lead to serious patient harm. … https://psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event

185. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47586/psn-pdf
     March 20, 2019 - Wrong-patient blood transfusion error: leveraging technology to overcome human error in intraoperative … Wrong-Patient Blood Transfusion Error: Leveraging Technology to Overcome Human Error in Intraoperative … https://psnet.ahrq.gov/issue/wrong-patient-blood-transfusion-error-leveraging-technology-overcome- human-error … Following a sentinel wrong-patient event, a multidisciplinary quality improvement team worked to enhance … https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery https://psnet.ahrq.gov

186. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/72678/psn-pdf
     January 27, 2021 - Health information technology-related wrong-patient errors: context is critical. … This study analyzed the processes of care involved in 1,189 wrong-patient events.  … The authors recommend several strategies for reducing wrong-patient errors.  … https://psnet.ahrq.gov/issue/health-information-technology-related-wrong-patient-errors-context-critical … https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery https://psnet.ahrq.gov

187. Outcome of 6 years of protocol use for preventing wrong site office surgery. | PSNet
     psnet.ahrq.gov/issue/outcome-6-years-protocol-use-preventing-wrong-site-office-surgery
     February 10, 2012 - Study Outcome of 6 years of protocol use for preventing wrong site office surgery … Outcome of 6 years of protocol use for preventing wrong site office surgery. … This study describes the use of a tool to prevent wrong site procedures in a dermatologic surgery … Outcome of 6 years of protocol use for preventing wrong site office surgery. … Cheek March 1, 2012 A 62-year-old woman with skin cancer who experienced wrong-site

188. The use of patient digital facial images to confirm patient identity in a children's hospital's anesthesia information management system. | PSNet
     psnet.ahrq.gov/issue/use-patient-digital-facial-images-confirm-patient-identity-childrens-hospitals-anesthesia
     May 06, 2009 - The Universal Protocol was intended to prevent wrong site, wrong procedure and wrong person surgery … In an effort to reduce wrong-patient charting and near-miss events involving anesthesia, this study implemented … After implementation, only one instance of wrong-patient charting was documented; however, baseline data … October 5, 2022 Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient … Children's Hospitals Quality and Safety Professionals Anesthesiology Pediatric Surgery Wrong

189. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/838183/psn-pdf
     September 28, 2022 - Adding automation and independent dual verification to reduce wrong blood in tube (WBIT) events. … Adding automation and independent dual verification to reduce wrong blood in tube (WBIT) events. … https://psnet.ahrq.gov/issue/adding-automation-and-independent-dual-verification-reduce-wrong-blood- … tube-wbit-events Wrong blood in tube (WBIT) errors are rare but can lead to complications. … https://psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event

190. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866908/psn-pdf
     October 09, 2024 - Risk factors for wrong-site surgery: a study of 1,166 reports of informed consent and schedule errors … Risk factors for wrong-site surgery: a study of 1,166 reports of informed consent and schedule errors … https://psnet.ahrq.gov/issue/risk-factors-wrong-site-surgery-study-1166-reports-informed-consent-and- … found that inaccurate consent documents and procedural schedules can lead to patient harm, such as wrong-site … https://psnet.ahrq.gov/web-mm/informed-or-misled https://psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side

191. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73380/psn-pdf
     June 09, 2021 - Wrong Site Surgery–Wrong Tooth Extraction. … https://psnet.ahrq.gov/issue/wrong-site-surgery-wrong-tooth-extraction Wrong-site surgery in dentistry … This report examines a case of pediatric wrong tooth extraction to reveal how the application of safety … https://psnet.ahrq.gov/issue/wrong-site-surgery-wrong-tooth-extraction https://psnet.ahrq.gov/perspective

192. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47603/psn-pdf
     March 20, 2019 - Electronic patient identification for sample labeling reduces wrong blood in tube errors. … Electronic patient identification for sample labeling reduces wrong blood in tube errors. … https://psnet.ahrq.gov/issue/electronic-patient-identification-sample-labeling-reduces-wrong-blood-tube … - errors Wrong-patient errors in blood transfusion can lead to serious patient harm. … https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery https://psnet.ahrq.gov

193. Mark My Limb | PSNet
     psnet.ahrq.gov/web-mm/mark-my-limb
     February 10, 2015 - body site (usually right versus left mistakes) or on the wrong patient, or the performance of the wrong … The Joint Commission's Universal Protocol for the Prevention of Wrong Site, Wrong Procedure, and Wrong … Lessons learned: wrong site surgery. … A follow-up review of wrong site surgery. … Universal protocol for preventing wrong site, wrong procedure, wrong person surgery.

194. Blood and blood products transfusion errors: what can we do to improve patient safety. | PSNet
     psnet.ahrq.gov/issue/blood-and-blood-products-transfusion-errors-what-can-we-do-improve-patient-safety
     September 23, 2020 - Incorrect patient registration , application of the wrong label , and blood draw from the wrong patient … December 7, 2022 Serious hazards of transfusion: evaluating the dangers of a wrong patient … October 5, 2022 Factors associated with wrong blood in tube errors: an international … November 17, 2021 WebM&M Cases “This is the wrong patient's … : Evaluating a Near-Miss Wrong Transfusion Event January 29, 2020 Transfusion

195. Common general surgical never events: analysis of NHS England never event data. | PSNet
     psnet.ahrq.gov/issue/common-general-surgical-never-events-analysis-nhs-england-never-event-data
     April 14, 2021 - 2020 in the National Health Service (NHS) England and categorized them into three main categories: wrong-site … surgery (53.58%), retained items post-procedure (44.54%), and wrong implant/prosthesis (1.88%). … More Related Resources Patient Safety Primers Wrong-Site … , Wrong-Procedure, and Wrong-Patient Surgery December 15, 2024 … 2013 Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site

196. Getting the message: a quality improvement initiative to reduce pages sent to the wrong physician. | PSNet
     psnet.ahrq.gov/issue/getting-message-quality-improvement-initiative-reduce-pages-sent-wrong-physician
     April 30, 2014 - Getting the message: a quality improvement initiative to reduce pages sent to the wrong … Getting the message: a quality improvement initiative to reduce pages sent to the wrong physician. … This study redesigned a hospital's paging process to reduce pages sent to the wrong physician by adopting … Getting the message: a quality improvement initiative to reduce pages sent to the wrong physician. … Resources From the Same Author(s) Frequency and clinical importance of pages sent to the wrong

197. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/853773/psn-pdf
     September 27, 2023 - A Double “Never Event”: Wrong Patient and Wrong Side. September 27, 2023 Bellini A, Salcedo ES. … A Double “Never Event”: Wrong Patient and Wrong Side. PSNet [internet]. 2023. … https://psnet.ahrq.gov/primer/never-events https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery … https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery https://psnet.ahrq.gov … patient, wrong side, wrong site, or wrong procedure cases (28%), followed by structural or human factors

198. Oops, sorry, wrong patient! A patient verification process is needed everywhere, not just at the bedside. | PSNet
     psnet.ahrq.gov/issue/oops-sorry-wrong-patient-patient-verification-process-needed-everywhere-not-just-bedside
     March 15, 2022 - Newspaper/Magazine Article Oops, sorry, wrong patient! … Citation Text: Oops, sorry, wrong patient! … Copy URL Cite Citation Citation Text: Oops, sorry, wrong … Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong … Site, Wrong Procedure and Wrong Person Surgery.

199. Large-scale observational study of AI-based patient and surgical material verification system in ophthalmology: real-world evaluation in 37 529 cases. | PSNet
     psnet.ahrq.gov/issue/large-scale-observational-study-ai-based-patient-and-surgical-material-verification-system
     August 27, 2012 - Wrong-side and wrong-patient surgical errors can have devastating consequences. … More Related Resources Patient Safety Primers Wrong-Site … , Wrong-Procedure, and Wrong-Patient Surgery December 15, 2024 Grading recommendations … November 15, 2023 Insurance claims for wrong-side, wrong-organ, wrong-procedure, or wrong-person

200. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35875/psn-pdf
     May 21, 2013 - Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. … https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person- … , wrong-procedure, and wrong-person surgery. … Wrong-site, wrong-procedure, and wrong-patient errors are all now considered never events by the National … https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery