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Total Results: 4,259 records

Showing results for "wrong".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40201/psn-pdf
    February 09, 2011 - Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong Site … , Wrong Procedure and Wrong Person Surgery. … , Wrong Procedure and Wrong Person Surgery. … https://psnet.ahrq.gov/issue/use-anatomic-marking-form-alternative-universal-protocol-preventing-wrong-site-wrong … https://psnet.ahrq.gov/issue/use-anatomic-marking-form-alternative-universal-protocol-preventing-wrong-site-wrong

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854833/psn-pdf
    October 25, 2023 - issue/deficiencies-facility-leaders-response-critical-surgical-events-michael-e- debakey-va-medical Wrong-site … This report details five wrong-site surgeries and three instances of retained surgical items at one … Additionally, the medical center failed to fully report the provider responsible for three of the wrong-site … deficiencies-facility-leaders-response-critical-surgical-events-michael-e-debakey-va-medical https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery

  3. Verifying patient identity and site of surgery: improving compliance with protocol by audit and feedback. | PSNet

    psnet.ahrq.gov/issue/verifying-patient-identity-and-site-surgery-improving-compliance-protocol-audit-and-feedback
    October 26, 2010 - periodic audits and feedback to increase compliance with patient identification in the prevention of wrong-patient … and wrong-site surgery . … A related commentary [see link below] discusses the broader context of efforts to eliminate wrong-site … October 3, 2011 The wrong foot, and other tales of surgical error. … February 8, 2011 Incidence and root cause analysis of wrong-site pain management procedures

  4. Sharing lessons learned to prevent incorrect surgery. | PSNet

    psnet.ahrq.gov/issue/sharing-lessons-learned-prevent-incorrect-surgery
    July 16, 2015 - The Veterans Affairs (VA) system has published important studies on the incidence of wrong-site, wrong-procedure … , and wrong-patient surgery . … Same Author(s) Errors upstream and downstream to the Universal Protocol associated with wrong … March 25, 2020 Wrong-side thoracentesis: lessons learned from root cause analysis. … March 29, 2017 Errors upstream and downstream to the Universal Protocol associated with wrong

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36632/psn-pdf
    July 28, 2010 - Operating room briefings and wrong-site surgery. … Operating room briefings and wrong-site surgery. J Am Coll Surg. 2007;204(2):236-43. … https://psnet.ahrq.gov/issue/operating-room-briefings-and-wrong-site-surgery Although wrong-site surgeries … The Joint Commission's Universal Protocol for prevention of wrong-site surgeries requires performing … /incidence-patterns-and-prevention-wrong-site-surgery https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47118/psn-pdf
    August 08, 2018 - Wrong-site nerve blocks: a systematic literature review to guide principles for prevention. … Wrong-site nerve blocks: A systematic literature review to guide principles for prevention. … prevention Wrong-site procedures are considered never events, yet they continue to occur. … A WebM&M commentary discussed an incident involving a wrong-site nerve block. … https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery https://psnet.ahrq.gov

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39747/psn-pdf
    August 11, 2010 - Wrong-site sinus surgery in otolaryngology. … Wrong-site sinus surgery in otolaryngology. … found that many respondents had personal experience with wrong-site surgery. … https://psnet.ahrq.gov/issue/wrong-site-sinus-surgery-otolaryngology 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

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47605/psn-pdf
    January 17, 2019 - , wrong-procedure, and wrong- patient surgeries to be never events. … A WebM&M commentary examined an incident involving a wrong-side surgery. … assessment-incorrect-surgical-procedures-within-and-outside-operating-room-follow-study-us 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 … /primer/never-events https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38331/psn-pdf
    October 20, 2010 - Assessment of the implementation of a national patient safety alert to reduce wrong site surgery. … Assessment of the implementation of a national patient safety alert to reduce wrong site surgery. … https://psnet.ahrq.gov/issue/assessment-implementation-national-patient-safety-alert-reduce-wrong-site … - surgery Wrong-site surgery is a rare yet devastating outcome. … /issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery https://psnet.ahrq.gov

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44334/psn-pdf
    November 20, 2015 - Improvement in detection of wrong-patient errors when radiologists include patient photographs in their … Improvement in Detection of Wrong-Patient Errors When Radiologists Include Patient Photographs in Their … https://psnet.ahrq.gov/issue/improvement-detection-wrong-patient-errors-when-radiologists-include-patient … 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/issue/multiobserver-study-effects-including-point-care-patient-photographs-portable-radiography

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39999/psn-pdf
    November 10, 2010 - Wrong-patient, wrong-site procedures persist despite safety protocol. … https://psnet.ahrq.gov/issue/wrong-patient-wrong-site-procedures-persist-despite-safety-protocol This … - patient, wrong-site procedures. … https://psnet.ahrq.gov/issue/wrong-patient-wrong-site-procedures-persist-despite-safety-protocol https … ://psnet.ahrq.gov/issue/wrong-site-and-wrong-patient-procedures-universal-protocol-era-analysis-prospective-database

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39840/psn-pdf
    September 15, 2010 - Wrong-site craniotomy: analysis of 35 cases and systems for prevention. … Wrong-site craniotomy: analysis of 35 cases and systems for prevention. … https://psnet.ahrq.gov/issue/wrong-site-craniotomy-analysis-35-cases-and-systems-prevention This study … /primer/checklists https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery … https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40594/psn-pdf
    July 06, 2011 - The pain of wrong site surgery. July 6, 2011 Boodman SG. Washington Post. June 21, 2011:E1. … https://psnet.ahrq.gov/issue/pain-wrong-site-surgery This newspaper article reports on a case of wrong-site … https://psnet.ahrq.gov/issue/pain-wrong-site-surgery https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery … https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49791/psn-pdf
    April 01, 2017 - wrong side, wrong body part, wrong patient, or wrong procedure at the correct site.(2) Wrong-site errors … commonly involve symmetrical structures and are often wrong-sided errors.(3) Wrong-site procedures … procedures on the correct site, wrong implant, wrong-site errors) were performed outside of the OR. … references https://psnet.ahrq.gov//#references https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery … Wrong-site and wrong-patient procedures in the universal protocol era: analysis of a prospective database

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/847733/psn-pdf
    March 16, 2025 - This guidance shares evidence-based steps to address problems such as wrong patient errors and lack … pharmacists-reducing-medication-risk-medical-outpatient-clinics-retrospective-study-18 https://psnet.ahrq.gov/web-mm/medication-errors-retail-pharmacies-wrong-patient-wrong-instructions … https://psnet.ahrq.gov/web-mm/medication-errors-retail-pharmacies-wrong-patient-wrong-instructions

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837594/psn-pdf
    June 29, 2022 - Machine learning models outperform manual result review for the identification of wrong blood in tube … Machine learning models outperform manual result review for the identification of wrong blood in tube … https://psnet.ahrq.gov/issue/machine-learning-models-outperform-manual-result-review-identification- wrong-blood-tube … Wrong blood in tube (WBIT) errors can result in serious diagnostic and treatment errors, but may go … https://psnet.ahrq.gov/issue/machine-learning-models-outperform-manual-result-review-identification-wrong-blood-tube

  17. Increasing rate of detection of wrong-patient radiographs: use of photographs obtained at time of radiography. | PSNet

    psnet.ahrq.gov/issue/increasing-rate-detection-wrong-patient-radiographs-use-photographs-obtained-time-radiography
    June 13, 2015 - Study Increasing rate of detection of wrong-patient radiographs: use of photographs … Increasing Rate of Detection of Wrong-Patient Radiographs: Use of Photographs Obtained at Time of Radiography … June 13, 2015 Evaluation of near-miss wrong-patient events in radiology reports. … June 21, 2016 Improvement in detection of wrong-patient errors when radiologists include … November 20, 2015 Evaluation of near-miss wrong-patient events in radiology reports.

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851352/psn-pdf
    July 12, 2023 - The most frequent never events were wrong site or wrong patient surgery, wrong surgical procedure, and … identifying-list-healthcare-never-events-effect-system-change-systematic-review-and-narrative https://psnet.ahrq.gov/primer/never-events https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46436/psn-pdf
    May 30, 2018 - Effect of number of open charts on intercepted wrong- patient medication orders in an emergency department … Effect of number of open charts on intercepted wrong- patient medication orders in an emergency department … https://psnet.ahrq.gov/issue/effect-number-open-charts-intercepted-wrong-patient-medication-orders- … Researchers analyzed intercepted wrong-patient medication orders in an emergency department over a 6 … ://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44967/psn-pdf
    March 16, 2016 - Wrong site surgery: a critical incident analysis of a near miss. March 16, 2016 Tichanow S. … Wrong site surgery: A critical incident analysis of a near miss. … https://psnet.ahrq.gov/issue/wrong-site-surgery-critical-incident-analysis-near-miss Despite efforts … to prevent wrong-site surgeries, they continue to occur. … /primer/wrong-site-wrong-procedure-and-wrong-patient-surgery https://psnet.ahrq.gov/issue/using-near-misses-analysis-prevent-wrong-site-surgery
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