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Total Results: 1,062 records

Showing results for "wrong".

321. Targeted Medication Safety Best Practices for Hospitals. | PSNet
     psnet.ahrq.gov/issue/targeted-medication-safety-best-practices-hospitals
     January 26, 2023 - The 2024-2025 edition includes new practices that are associated with tranexamic acid wrong-route errors

322. Electronic Health Records | PSNet
     psnet.ahrq.gov/primer/electronic-health-records
     March 15, 2025 - that, while overall medication safety improved, new vulnerabilities emerged, including increases in wrong … patient, wrong medication, or wrongly timed orders.

323. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74239/psn-pdf
     January 12, 2022 - https://psnet.ahrq.gov/issue/high-risk-medications-hospitalized-elderly-adults-are-we-making-it-easy-do-wrong-thing

324. On O.R. Off? | PSNet
     psnet.ahrq.gov/web-mm/or
     August 22, 2013 - recurrent elements in unanticipated adverse events.( 1 ) As a practicing anesthesiologist, I have had the wrong … Many things had to go wrong for all these mistakes (ie, the "holes in the This error was the result of … Many things had to go wrong for all these mistakes (ie, the "holes in the Swiss cheese") to line up.( … January 29, 2014 When surgery goes wrong: weighing up the risks.

325. Calibrate Dx: A Resource to Improve Diagnostic Decisions. | PSNet
     psnet.ahrq.gov/issue/calibrate-dx-resource-improve-diagnostic-decisions
     September 08, 2021 - Delayed, wrong, and missed diagnoses are common challenges for patients, families, and clinicians,

326. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33563/psn-pdf
     September 16, 2024 - web-mm/implicit-biases-interprofessional-communication-and-power-dynamics https://psnet.ahrq.gov/issue/wrong-patient … https://psnet.ahrq.gov/issue/wrong-patient https://psnet.ahrq.gov/issue/surveys-patient-safety-culture

327. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33568/psn-pdf
     June 15, 2024 - /dont-wait-collect-accurate-weight-case-subtherapeutic-insulin-therapy https://psnet.ahrq.gov/issue/wrong-patient … Current Context The Joint Commission has mandated use of RCA to analyze sentinel events (such as wrong-site

328. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73190/psn-pdf
     April 28, 2021 - flaw-medicine-addressing-racial-and-gender-disparities-critical-care https://psnet.ahrq.gov/issue/your-diagnosis-was-wrong-could-doctor-bias-have-been-factor

329. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36442/psn-pdf
     July 23, 2023 - evaluating-efforts-optimize-teamstepps-implementation-surgical-and-pediatric-intensive-care https://psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong

330. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867651/psn-pdf
     February 26, 2025 - Definition of Safety and Safety Management Principle Safety I defies safety as having as few things go wrong … causality credo, which he defines as “the belief that adverse outcomes happen because something goes wrong … intractability, and complexity of healthcare work, the surprise is not that things occasionally go wrong … Rather than reacting retrospectively to what has gone wrong, Safety II attempts to understand the interaction … proposes to understand how things usually go right as a basis for explaining how things occasionally go wrong

331. Safety I, Safety II, and the New Views of Safety | PSNet
     psnet.ahrq.gov/primer/safety-i-safety-ii-and-new-views-safety
     October 02, 2024 - Definition of Safety and Safety Management Principle Safety I defies safety as having as few things go wrong … causality credo , which he defines as “the belief that adverse outcomes happen because something goes wrong … intractability, and complexity of healthcare work, the surprise is not that things occasionally go wrong … Rather than reacting retrospectively to what has gone wrong, Safety II attempts to understand the interaction … proposes to understand how things usually go right as a basis for explaining how things occasionally go wrong

332. Active Error (or Active Failure) | PSNet
     psnet.ahrq.gov/glossary/active-error-or-active-failure
     September 13, 2021 - This person may literally be holding a scalpel (e.g., an orthopedist operating on the wrong leg) or figuratively

333. Thinking in three's: changing surgical patient safety practices in the complex modern operating room. | PSNet
     psnet.ahrq.gov/issue/thinking-threes-changing-surgical-patient-safety-practices-complex-modern-operating-room
     April 28, 2021 - This commentary explores strategies to prevent surgical fires, wrong-site surgeries , and retained surgical

334. Never Events for Hospital Care in Canada: Safer Care for Patients. | PSNet
     psnet.ahrq.gov/issue/never-events-hospital-care-canada-safer-care-patients
     August 12, 2020 - effort to determine a list of never events for hospital care in Canada, including patient suicide , wrong-site

335. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60306/psn-pdf
     May 06, 2020 - identified, 10.8% were due to a medication error; nearly all of these errors (93.2%) were attributed to the wrong

336. The Role of Bar Coding and Smart Pumps in Safety | PSNet
     psnet.ahrq.gov/perspective/role-bar-coding-and-smart-pumps-safety
     September 01, 2008 - While smart infusion pumps alone may prevent pump programming errors, they cannot prevent giving the wrong … drug or the wrong concentration, or giving the drug to the wrong patient. … multicenter study that included 24 hospitals, Barker found an administration error rate of 11%, excluding wrong-time … In both cases, errors led to the wrong concentration of IV heparin being administered, resulting in 1000 … Here, the barcode reader is connected to the smart pump to prevent wrong medication and wrong concentration

337. The systems approach to medicine: controversy and misconceptions. | PSNet
     psnet.ahrq.gov/issue/systems-approach-medicine-controversy-and-misconceptions
     June 24, 2020 - approach is often misunderstood to ascribe responsibility for failure to the system when things go wrong

338. Moving towards a Safety II approach. | PSNet
     psnet.ahrq.gov/issue/moving-towards-safety-ii-approach
     May 18, 2022 - Efforts to improve patient safety have evolved beyond investigating what went wrong to understanding

339. Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room | PSNet
     psnet.ahrq.gov/web-mm/saline-flush-leads-acute-paralysis-awake-patient-risks-improper-medication-labeling
     February 01, 2019 - events, 276 were medication errors, of which the most common type was accidental administration of the wrong … dose (N = 84), followed by accidental administration of the wrong syringe (N = 49). … Care Professions May 1, 2011 WebM&M Cases Wrong

340. Improving safety and quality of care with enhanced teamwork through operating room briefings. | PSNet
     psnet.ahrq.gov/issue/improving-safety-and-quality-care-enhanced-teamwork-through-operating-room-briefings
     May 11, 2019 - Operating room briefings or time-outs are mandated by The Joint Commission as a strategy to prevent wrong-site