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Showing results for "wrong".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60565/psn-pdf
    June 03, 2020 - But hospitals got some things wrong. June 3, 2020 Ofri D. The public has been forgiving. … But hospitals got some things wrong. New York Times. 2020; May 21. … https://psnet.ahrq.gov/issue/public-has-been-forgiving-hospitals-got-some-things-wrong The complexity … https://psnet.ahrq.gov/issue/public-has-been-forgiving-hospitals-got-some-things-wrong https://psnet.ahrq.gov

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40707/psn-pdf
    March 11, 2013 - More than words: patients' views on apology and disclosure when things go wrong in cancer care. … More than words: patients' views on apology and disclosure when things go wrong in cancer care. … https://psnet.ahrq.gov/issue/more-words-patients-views-apology-and-disclosure-when-things-go-wrong- … efforts have included implementation of formal disclosure policies, such as Harvard’s When Things Go Wrong … https://psnet.ahrq.gov/issue/more-words-patients-views-apology-and-disclosure-when-things-go-wrong-cancer-care

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36604/psn-pdf
    June 04, 2024 - Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site … issue/national-quality-forum https://psnet.ahrq.gov/primer/never-events https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43393/psn-pdf
    July 30, 2014 - analyzes the evidence for surgical checklist implementation to determine its usefulness in preventing wrong-site … effectiveness-surgical-safety-checklist-correcting-errors-literature-review-applying-reasons https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery … issue/surgical-checklists-systematic-review-impacts-and-implementation https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36430/psn-pdf
    March 28, 2011 - Experience of wrong site surgery and surgical marking practices among clinicians in the UK. … Experience of wrong site surgery and surgical marking practices among clinicians in the UK. … https://psnet.ahrq.gov/issue/experience-wrong-site-surgery-and-surgical-marking-practices-among- clinicians-uk … The investigators analyzed incidents of wrong-site surgery and surgical marking practices in the United … https://psnet.ahrq.gov/issue/experience-wrong-site-surgery-and-surgical-marking-practices-among-clinicians-uk

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49419/psn-pdf
    October 01, 2003 - Understand the key components of the Universal Protocol for eliminating wrong site, wrong procedure, … wrong person surgery. … Recently, JCAHO released a Universal Protocol for preventing wrong person, wrong procedure, and wrong … Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. [ go to related … Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. [ go to related

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49650/psn-pdf
    March 01, 2012 - The patient returned to his referring physician, who immediately realized that the wrong lesion (the … surgery as any surgery performed on the wrong site or the wrong patient, or performance of the wrong … The patient in this case self-identified the wrong surgical site. … A follow-up review of wrong site surgery. Sentinel Event Alert. December 5, 2001. … Outcome of 6 years of protocol use for preventing wrong site office surgery.

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46688/psn-pdf
    January 01, 2018 - New solutions to reduce wrong route medication errors. … New solutions to reduce wrong route medication errors. … https://psnet.ahrq.gov/issue/new-solutions-reduce-wrong-route-medication-errors Tubing misconnections … This commentary discusses design strategies that can address wrong route medication administration, … https://psnet.ahrq.gov/issue/new-solutions-reduce-wrong-route-medication-errors https://psnet.ahrq.gov

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40377/psn-pdf
    April 20, 2011 - lessons-learned-use-event-reporting-nurses-improve-patient-safety-and-quality 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

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40020/psn-pdf
    September 20, 2011 - the usual clinical focus, this article discusses a never event—a case of a patient who underwent the wrong … year-old-woman-incorrect-operation-left-hand https://psnet.ahrq.gov/primer/never-events https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery … language-proficiency-and-adverse-events-us-hospitals-pilot-study https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37059/psn-pdf
    September 30, 2011 - Preventable errors in the operating room--part 2: retained foreign objects, sharps injuries, and wrong … Preventable errors in the operating room--part 2: retained foreign objects, sharps injuries, and wrong … psnet.ahrq.gov/issue/preventable-errors-operating-room-part-2-retained-foreign-objects-sharps- injuries-and-wrong … Building on part one of this two-part series, the authors discuss wrong-site surgeries and needle stick … psnet.ahrq.gov/issue/preventable-errors-operating-room-part-2-retained-foreign-objects-sharps-injuries-and-wrong

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851656/psn-pdf
    July 26, 2023 - adverse events were improperly functioning equipment (e.g., broken scopes or smoking light cords), wrong … /preventable-mortality-after-common-urological-surgery-failing-rescue https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery

  13. Randomized controlled evaluation of an insulin pen storage policy. | PSNet

    psnet.ahrq.gov/issue/randomized-controlled-evaluation-insulin-pen-storage-policy
    January 23, 2017 - This quality improvement intervention sought to decrease wrong-patient errors with insulin pens by … Development and implementation of a subcutaneous insulin pen label bar code scanning protocol to prevent wrong-patient … Effect of restriction of the number of concurrently open records in an electronic health record on wrong-patient … April 16, 2018 Intercepting wrong-patient orders in a computerized provider order entry … See More About The Topic Hospitals Health Care Providers Endocrinology Insulin Wrong

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/858165/psn-pdf
    December 13, 2023 - When public health goes wrong: toward a new concept of public health error. … When public health goes wrong: toward a new concept of public health error. … https://psnet.ahrq.gov/issue/when-public-health-goes-wrong-toward-new-concept-public-health-error Public … https://psnet.ahrq.gov/issue/when-public-health-goes-wrong-toward-new-concept-public-health-error https

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46811/psn-pdf
    May 17, 2018 - psnet.ahrq.gov/issue/surgical-procedure-grid-safety-and-operating-room-communication-multisite- surgery Wrong-patient … and wrong-site surgeries are considered never events. … authors envision the tool to enhance team communication and preparation, which should reduce risk of wrong-site … surgical-procedure-grid-safety-and-operating-room-communication-multisite-surgery https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36177/psn-pdf
    April 19, 2011 - Wrong site surgery. April 19, 2011 Fraser SG, Adams W. Wrong site surgery. … https://psnet.ahrq.gov/issue/wrong-site-surgery The authors provide an overview of wrong site surgery … https://psnet.ahrq.gov/issue/wrong-site-surgery

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73280/psn-pdf
    May 19, 2021 - 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%). … web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough https://psnet.ahrq.gov/issue/wrong-site-surgery … -1 https://psnet.ahrq.gov/issue/wrong-site-surgery-1

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73139/psn-pdf
    April 14, 2021 - Use of BCMA decreased wrong medication and wrong dosage errors, and wrong patient, wrong form, and ambiguous

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35312/psn-pdf
    January 02, 2017 - Medication errors involving wrong administration technique. … Medication Errors Involving Wrong Administration Technique. … https://psnet.ahrq.gov/issue/medication-errors-involving-wrong-administration-technique This study analyzed … Drawing from more than 7200 wrong administration technique errors, a number of true case examples are … https://psnet.ahrq.gov/issue/medication-errors-involving-wrong-administration-technique

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35885/psn-pdf
    December 14, 2007 - 'Wrong site' surgeries on the rise. December 14, 2007 Davis R. … https://psnet.ahrq.gov/issue/wrong-site-surgeries-rise This article reports on a recent AHRQ-funded … study on the incidence of wrong-site surgery and shares various perspectives on the issue. … https://psnet.ahrq.gov/issue/wrong-site-surgeries-rise https://psnet.ahrq.gov/issue/incidence-patterns-and-prevention-wrong-site-surgery
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