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Total Results: 1,062 records

Showing results for "wrong".

341. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49757/psn-pdf
     April 01, 2016 - The intern immediately notified the nurse that argatroban had been administered to the wrong patient … satisfaction.(7-9) Immersion into the situation of interest is the first step in recognizing what might be wrong … with the situation, and it supports the ability to anticipate what may go wrong in the future.

342. Duplicate Therapies in Retail Pharmacy | PSNet
     psnet.ahrq.gov/web-mm/duplicate-therapies-retail-pharmacy
     August 05, 2022 - May 16, 2022 WebM&M Cases Wrong Catheter in the … WebM&M Cases Medication Errors in Retail Pharmacies: Wrong … Patient, Wrong Instructions. … Polypharmacy May 1, 2013 WebM&M Cases Bad Writing, Wrong

343. Failure Mode and Effect Analysis (FMEA) | PSNet
     psnet.ahrq.gov/glossary/failure-mode-and-effect-analysis-fmea
     September 13, 2021 - With the process mapped out, the FMEA then continues by identifying the ways in which each step can go wrong

344. External Inquiry into the adverse incident that occurred at Queen's Medical Centre, Nottingham, 4th January 2001. | PSNet
     psnet.ahrq.gov/issue/external-inquiry-adverse-incident-occurred-queens-medical-centre-nottingham-4th-january-2001
     September 10, 2014 - Department of Health report details a series of errors that led to the death of a young man due to wrong

345. In Conversation With… Erik Hollnagel, PhD | PSNet
     psnet.ahrq.gov/perspective/conversation-erik-hollnagel-phd
     February 26, 2025 - The basic idea is that even when something goes wrong, people were trying to do what they thought was … We can do it by helping people talk about their work, not talk about what has gone wrong but simply talk … what you do when things go well—rather than in the sense of Safety-I, finding the causes for what went wrong

346. Root Cause Analysis | PSNet
     psnet.ahrq.gov/primer/root-cause-analysis
     March 30, 2022 - Current Context The Joint Commission has mandated use of RCA to analyze sentinel events (such as wrong-site … July 20, 2022 View More Related WebM&M Root Cause Analysis Gone Wrong

347. Which End Is Which? | PSNet
     psnet.ahrq.gov/web-mm/which-end-which
     February 09, 2011 - second is that a floppy, redundant transverse colon is misidentified as sigmoid colon, so that the wrong … step.( 1-3 ) In this case, the transverse colon was likely misidentified as the sigmoid colon, and the wrong … If the wrong end has been brought out, the scope will demonstrate normal colon lumen.

348. A Conversation with Patient Safety Officers. | PSNet
     psnet.ahrq.gov/issue/conversation-patient-safety-officers
     April 30, 2024 - August 17, 2021 Neuromuscular blocking agents: reducing associated wrong-drug errors.

349. HospitalInspections.org | PSNet
     psnet.ahrq.gov/issue/hospitalinspectionsorg
     February 24, 2025 - February 9, 2022 Reducing the Risks of Wrong-Site Surgery: Safety Practices from The

350. Learning Not Blaming. | PSNet
     psnet.ahrq.gov/issue/learning-not-blaming
     March 28, 2018 - recommendations in the three reports included the need to support open discussions about what went wrong

351. Joint Commission Center for Transforming Healthcare. | PSNet
     psnet.ahrq.gov/issue/joint-commission-center-transforming-healthcare
     February 28, 2018 - number of challenging areas (the first three are hand hygiene, handoff communication , and preventing wrong

352. Adverse Health Events in Minnesota: Annual Reports. | PSNet
     psnet.ahrq.gov/issue/adverse-health-events-minnesota-15th-annual-public-report
     February 28, 2015 - Quality Forum has defined 29 never events —patient safety problems that should never occur, such as wrong-site

353. The malpractice mess. | PSNet
     psnet.ahrq.gov/issue/malpractice-mess
     November 14, 2018 - June 26, 2019 Death by 1,000 clicks: where electronic health records went wrong.

354. Resilient Healthcare and the Safety-I and Safety-II Frameworks | PSNet
     psnet.ahrq.gov/perspective/resilient-healthcare-and-safety-i-and-safety-ii-frameworks
     December 14, 2022 - Defining Safety Traditional views define safety as a state in which as few things as possible go wrong … outlook inverts the Safety-I paradigm and seeks to understand what is going well, as opposed to what went wrong … Safety-I is the approach to understanding something that went wrong by determining why it went wrong. … Safety-I focuses on what went wrong, and how do we stop it from happening.

355. Updates in the Role of Health IT in Patient Safety | PSNet
     psnet.ahrq.gov/perspective/updates-role-health-it-patient-safety
     January 31, 2020 - to these examples, barcode scanning nursing protocols may have the potential to reduce the risk of wrong-patient … that the use of CPOE reduces the overall medication error rate as well as specific error rates for wrong … dose, wrong drug, administration frequency, administration route, and drug-to-drug interaction errors

356. Reducing the Safety Hazards of Monitor Alert and Alarm Fatigue | PSNet
     psnet.ahrq.gov/perspective/reducing-safety-hazards-monitor-alert-and-alarm-fatigue
     May 01, 2016 - seemed logical to build in alarms and alerts to let clinicians know when something is—or might be —wrong … to try to get the attention of the nurse down at the other end of the hall to come and see what was wrong … alarms—we have crisis, warning, advisory, textual—what would really catch your attention that something was wrong … in the unit and everything was quiet—if there were no alarms, no sounds, I would know something was wrong … predictive algorithm about whether you as a patient are stable or going in the right direction or in the wrong

357. Medication prescribing errors involving the route of administration. | PSNet
     psnet.ahrq.gov/issue/medication-prescribing-errors-involving-route-administration
     January 12, 2011 - These errors were common, most frequently involving prescribing for the wrong route (eg, orally instead

358. Five Steps to Safer Health Care. | PSNet
     psnet.ahrq.gov/issue/five-steps-safer-health-care
     July 21, 2021 - July 21, 2021 Reducing the Risks of Wrong-Site Surgery: Safety Practices from The Joint

359. Joint Commission International Center for Patient Safety. | PSNet
     psnet.ahrq.gov/issue/joint-commission-international-center-patient-safety
     November 27, 2018 - January 1, 2021 Reducing the Risks of Wrong-Site Surgery: Safety Practices from The Joint

360. Stem the Tide: Addressing the Opioid Epidemic. | PSNet
     psnet.ahrq.gov/issue/stem-tide-addressing-opioid-epidemic
     April 15, 2021 - leader reflects on ‘To Err is Human’ report December 11, 2019 Reducing the Risks of Wrong-Site