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Total Results: 1,062 records

Showing results for "wrong".

301. Moving beyond the weekend effect: how can we best target interventions to improve patient care? | PSNet
     psnet.ahrq.gov/issue/moving-beyond-weekend-effect-how-can-we-best-target-interventions-improve-patient-care
     September 09, 2015 - 30, 2023 The AHRQ Report on Diagnostic Errors in the Emergency Department: the wrong … answer to the wrong question.

302. Anticoagulant medication errors in nursing homes: characteristics, causes, outcomes, and association with patient harm. | PSNet
     psnet.ahrq.gov/issue/anticoagulant-medication-errors-nursing-homes-characteristics-causes-outcomes-and-association
     December 15, 2011 - September 23, 2020 The AHRQ Report on Diagnostic Errors in the Emergency Department: the wrong … answer to the wrong question.

303. A qualitative evaluation of the barriers and facilitators toward implementation of the WHO surgical safety checklist across hospitals in England: lessons from the "Surgical Checklist Implementation Project." | PSNet
     psnet.ahrq.gov/issue/qualitative-evaluation-barriers-and-facilitators-toward-implementation-who-surgical-safety
     January 19, 2016 - June 22, 2016 Compliance with a time-out procedure intended to prevent wrong surgery … July 24, 2013 Information needs in operating room teams: what is right, what is wrong

304. Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients. | PSNet
     psnet.ahrq.gov/issue/root-cause-analysis-reports-help-identify-common-factors-delayed-diagnosis-and-treatment
     October 24, 2018 - October 24, 2018 Errors upstream and downstream to the Universal Protocol associated with wrong … April 25, 2016 Wrong-side thoracentesis: lessons learned from root cause analysis.

305. The Lost Start Date: an Unknown Risk of E-prescribing | PSNet
     psnet.ahrq.gov/web-mm/lost-start-date-unknown-risk-e-prescribing
     December 02, 2020 - various components of this system require a situational awareness of the various things that can go wrong … ) Association of display of patient photographs in the electronic health record with wrong-patient … Effect of restriction of the number of concurrently open records in an electronic health record on wrong-patient … WebM&M Cases Multiple Levels Involved in Prescribing the Wrong … June 16, 2019 WebM&M Cases Bad Writing, Wrong Medication

306. Cups of Error | PSNet
     psnet.ahrq.gov/web-mm/cups-error
     January 12, 2011 - When the time came to administer the medication(s), the student in this case picked up the wrong cup … different student expecting to give the above medications reviewed the ones in her cup and discovered the wrong … students conclude any suspicions they might have about the accuracy of statements and actions must be wrong

307. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33605/psn-pdf
     March 12, 2021 - variability, dose preparation is uniquely challenging in pediatric populations, which increases risk for wrong … Wrong dose, missing doses, and wrong medication are the most commonly reported administration errors … To help mitigate of wrong dose errors, warfarin tablet colors are standardized by their strength across

308. Technology as a Tool for Improving Patient Safety | PSNet
     psnet.ahrq.gov/perspective/technology-tool-improving-patient-safety
     April 26, 2023 - Medication Safety Measure Development project, aims to develop and validate measure specifications for wrong-patient … , wrong-dose, wrong-medication, wrong-route, and wrong-frequency medication orders within EHR systems

309. Radiation Safety | PSNet
     psnet.ahrq.gov/primer/radiation-safety
     September 15, 2024 - 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

310. High Reliability Organization (HRO) Principles and Patient Safety | PSNet
     psnet.ahrq.gov/perspective/high-reliability-organization-hro-principles-and-patient-safety
     February 26, 2025 - orientation can help is by helping people be systematic and intentional about things that have gone wrong … of the system,” we invite ourselves to think more intentionally and anticipate things that might go wrong … And then, when things do go wrong, how do we put a process in place to adapt and contain them? … Let us talk about what went wrong. Who did not get listened to in our team?” … Are we making sure we are thinking preemptively about what could go wrong?

311. In Conversation with Timothy Vogus about High Reliability Organization (HRO) Principles and Patient Safety | PSNet
     psnet.ahrq.gov/perspective/conversation-timothy-vogus-about-high-reliability-organization-hro-principles-and
     February 26, 2025 - orientation can help is by helping people be systematic and intentional about things that have gone wrong … of the system,” we invite ourselves to think more intentionally and anticipate things that might go wrong … And then, when things do go wrong, how do we put a process in place to adapt and contain them? … Let us talk about what went wrong. Who did not get listened to in our team?” … Are we making sure we are thinking preemptively about what could go wrong?

312. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867757/psn-pdf
     March 12, 2025 - medication-administration-errors https://psnet.ahrq.gov/perspective/medication-safety-nursing-homes-whats-wrong-and-how-fix-it

313. The Different Count Contributions to Retention (pdf file)
     psnet.ahrq.gov/sites/default/files/2024-10/The%20Different%20Count%20Contributions%20to%20Retention.pdf
     January 01, 2024 - Types of events which required reporting included, medication errors, wrong surgery cases, child abduction … A frequent finding in the retained sponge cases was that the final sponge count was wrong. … To understand why the sponge counts were wrong requires a deeper analysis of the policies and practices … identified, nursing communication strategies are employed to inform the surgeon that something is wrong

314. Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff. | PSNet
     psnet.ahrq.gov/issue/personal-protective-equipment-preventing-highly-infectious-diseases-due-exposure-contaminated
     April 23, 2014 - February 15, 2023 The AHRQ Report on Diagnostic Errors in the Emergency Department: the wrong … answer to the wrong question.

315. Primers | PSNet
     psnet.ahrq.gov/primers-0
     March 15, 2025 - (1) Fatigue and Sleep Deprivation (2) Identification Errors (2) Wrong … Intraoperative Complications (4) Retained Surgical Instruments and Sponges (3) Wrong-Site … Safety I defines safety as having as few things go wrong as possible whereas the Safety II perspective

316. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33592/psn-pdf
     December 15, 2024 - Errors are defined as "an act of commission (doing something wrong) or omission (failing to do the right … Error: a broader term referring to any act of commission (doing something wrong) or omission (failing

317. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47336/psn-pdf
     March 04, 2019 - psnet.ahrq.gov/issue/improving-patient-family-and-clinician-experience-after-harmful-events-when-things-go-wrong

318. Inadvertent Castration | PSNet
     psnet.ahrq.gov/web-mm/inadvertent-castration
     October 27, 2010 - Wrong-site Surgery and Other Cognitive Errors In this case, the surgeon almost certainly never considered … misalignment of the stars links this case and many other common intra-operative adverse events involving wrong-site … Strategies to avoid wrong-site surgery. In: Shojania KG, Duncan BW, McDonald KM, Wachter RM, eds. … March 3, 2011 Information needs in operating room teams: what is right, what is wrong

319. Incident Reporting: More Attention to the Safety Action Feedback Loop, Please | PSNet
     psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please
     September 01, 2011 - Another problem is that the wrong types of events tend to get reported. … So, I would say reporting the wrong type of events is another problem, meaning that incident reports … What is it about a fall that's different than a wrong-site surgery that—assuming it was painless and … You could imagine what some of them would be, any time there's a wrong patient involved or a wrong medication … Whereas a lot of other incidents and serious things like wrong-site surgery where there will be so many

320. Polypharmacy | PSNet
     psnet.ahrq.gov/web-mm/polypharmacy
     March 01, 2007 - WebM&M Cases Medication Errors in Retail Pharmacies: Wrong … Patient, Wrong Instructions. … February 1, 2012 WebM&M Cases Bad Writing, Wrong