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Total Results: 4,259 records

Showing results for "wrong".

3381. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867980/psn-pdf
      March 25, 2025 - that clinicians and teams fall into during the diagnostic process, leading to missed, delayed, or wrong … may help avoid diagnostic error Proactively discussing the diagnostic process (as well as potential wrong

3382. Advancing Patient Safety Through State Reporting Systems | PSNet
      psnet.ahrq.gov/perspective/advancing-patient-safety-through-state-reporting-systems
      June 01, 2007 - Analysis of wrong-patient/wrong-site surgical errors led to development of the New York preoperative … (Go to table citation in commentary) Surgical Events Surgery performed on the wrong body … part Surgery performed on the wrong patient Wrong surgical procedure performed on a patient Unintended … Patient death or serious disability associated with a medication error (e.g., errors involving the wrong … drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration

3383. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44140/psn-pdf
      July 15, 2015 - Openness and Honesty When Things Go Wrong: the Professional Duty of Candour. … https://psnet.ahrq.gov/issue/openness-and-honesty-when-things-go-wrong-professional-duty-candour Open … https://psnet.ahrq.gov/issue/openness-and-honesty-when-things-go-wrong-professional-duty-candour https

3384. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39073/psn-pdf
      February 20, 2010 - my-five-moments-hand-hygiene-user-centred-design-approach-understand-train-monitor-and-report https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery

3385. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44520/psn-pdf
      September 30, 2015 - issue/quantifying-and-characterizing-adverse-events-dermatologic-surgery https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery

3386. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45557/psn-pdf
      October 27, 2016 - https://psnet.ahrq.gov/primer/checklists https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery

3387. Misidentifying the Unidentified – John Doe and the EHR | PSNet
      psnet.ahrq.gov/web-mm/misidentifying-unidentified-john-doe-and-ehr
      September 27, 2017 - data to the wrong patient have been opened. … And while labs and diagnostics that are erroneously linked to the wrong patient can lead to secondary … or tertiary errors such as wrong treatments based on interpreting wrong information, blood banking errors—a … May 10, 2023 Adding automation and independent dual verification to reduce wrong blood … May 29, 2019 Wrong-patient blood transfusion error: leveraging technology to overcome

3388. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35786/psn-pdf
      May 07, 2007 - When Things Go Wrong: Responding to Adverse Events. … https://psnet.ahrq.gov/issue/when-things-go-wrong-responding-adverse-events This consensus paper of … https://psnet.ahrq.gov/issue/when-things-go-wrong-responding-adverse-events https://psnet.ahrq.gov//#

3389. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39710/psn-pdf
      July 28, 2010 - found that 37% of medication errors were repeated one or more times in nursing home settings, with wrong … dosage and wrong administration as the most frequent causes. … repeat-medication-errors-nursing-homes-contributing-factors-and-their-association-patient https://psnet.ahrq.gov/issue/medication-errors-involving-wrong-administration-technique

3390. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43139/psn-pdf
      April 23, 2014 - first-do-no-harm-part-1-case-study-systems-failure https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery

3391. Workplace Safety in Health Care | PSNet
      psnet.ahrq.gov/perspective/workplace-safety-health-care
      January 01, 2017 - results, but after people get the rhythm of learning—ideally in real time, by identifying what went wrong … from what we were doing in workplace safety, namely to identify as quickly as possible anything gone wrong—including … But it's not true that you cannot systematically eliminate things gone wrong if you're constantly improving … what you do by learning from things gone wrong. … It's amazing if you look at the number of medication errors in the country—starting with the wrong meds

3392. In Conversation with...Geri Amori, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-withgeri-amori-phd
      December 01, 2010 - If I admit to you that I don't know if I did wrong, or I did do wrong, or we don't know what's going … We wait for something to go wrong. … And if something goes wrong, then say, "Well, we're going to work on that, too." … (e.g., lack of clear lines of communication and responsibility; lack of a robust process to prevent wrong

3393. In Conversation With… Paul H. O'Neill, MPA | PSNet
      psnet.ahrq.gov/perspective/conversation-paul-h-oneill-mpa
      January 01, 2017 - results, but after people get the rhythm of learning—ideally in real time, by identifying what went wrong … from what we were doing in workplace safety, namely to identify as quickly as possible anything gone wrong—including … But it's not true that you cannot systematically eliminate things gone wrong if you're constantly improving … what you do by learning from things gone wrong. … It's amazing if you look at the number of medication errors in the country—starting with the wrong meds

3394. Diagnostic Errors in Medicine: What Do Doctors and Umpires Have in Common? | PSNet
      psnet.ahrq.gov/perspective/diagnostic-errors-medicine-what-do-doctors-and-umpires-have-common
      February 01, 2007 - Advice to Reduce "Fast and Frugal" Cognitive Errors in Diagnosis Be aware of the odds of being wrong … residents were confident about a diagnosis in a significant number of patients in whom they were actually wrong … people have looked at physician autonomy and said, "Why should autonomy be preserved when we get it wrong … Remember with any system, if you put rubbish into it—for example, if you put the wrong numbers into a … calculator—your answers are going to be wrong.

3395. Getting Into Patient Safety: A Personal Story | PSNet
      psnet.ahrq.gov/perspective/getting-patient-safety-personal-story
      August 01, 2006 - In fact, most of the discussions were about all of the other kinds of things that can go wrong. … March 29, 2023 Insurance claims for wrong-side, wrong-organ, wrong-procedure, or … wrong-person surgical errors: a retrospective study for 10 years.

3396. Discrepant advanced directives and code status orders: a preventable medical error. | PSNet
      psnet.ahrq.gov/issue/discrepant-advanced-directives-and-code-status-orders-preventable-medical-error
      October 31, 2018 - Journal Article Discrepant advanced directives and code status orders: a preventable medical error. Citation Text: Meisenberg B, Zaidi S, Franks L, et al. Discrepant Advanced Directives and Code Status Orders: A Preventable Medical Error. J Hosp Med. 2019;14(10):716-718. doi:10.12788/jhm…

3397. Mistaken Identity | PSNet
      psnet.ahrq.gov/web-mm/mistaken-identity
      December 18, 2014 - After further investigation, the intern realized that the orthopedic team had evaluated the wrong patient—the … For example, the Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery … The wrong patient. Ann Intern Med. 2002;136:826-833. [go to PubMed] 4. Seiden SC, Barach P. … Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: are they preventable? … Universal protocol for preventing wrong site, wrong procedure, wrong person surgery.

3398. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33858/psn-pdf
      May 01, 2018 - Then to say, "Doctor, you aren't sharing data, you are blocking," is just wrong. … How well did that work, where did they get it right, and where did they get it wrong? … Tell me why that's wrong. … They've tried it before in some cases and gotten it wrong.

3399. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33866/psn-pdf
      September 01, 2018 - I started thinking about how to improve communication when things go wrong, cowrote the facilitator's … and honest communication, and organizational culture to help patients and families when things go wrong … psnet.ahrq.gov/issue/improving-patient-family-and-clinician-experience-after-harmful-events-when-things-go-wrong … I started off in patient safety thinking about how we could do a better job when things go wrong.

3400. Retained Surgical Items: Causation and Prevention | PSNet
      psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
      January 04, 2024 - a post hoc conclusion that the counts documented in these cases (i.e., usually correct counts) were wrong … January 15, 2025 Patient Safety Primers Wrong-Site, Wrong-Procedure … , and Wrong-Patient Surgery December 15, 2024 Guidelines in Practice.