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psnet.ahrq.gov/node/40142/psn-pdf
April 04, 2011 - Prevention of 3 "never events" in the operating room:
fires, gossypiboma, and wrong-site surgery. … Prevention of 3 "never events" in the operating room: fires,
gossypiboma, and wrong-site surgery. … https://psnet.ahrq.gov/issue/prevention-3-never-events-operating-room-fires-gossypiboma-and-wrong-site … https://psnet.ahrq.gov/issue/prevention-3-never-events-operating-room-fires-gossypiboma-and-wrong-site-surgery … https://psnet.ahrq.gov/issue/prevention-3-never-events-operating-room-fires-gossypiboma-and-wrong-site-surgery
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psnet.ahrq.gov/node/42360/psn-pdf
April 16, 2018 - Wrong-patient medication errors: an analysis of event
reports in Pennsylvania and strategies for prevention … https://psnet.ahrq.gov/issue/wrong-patient-medication-errors-analysis-event-reports-pennsylvania-and- … strategies-prevention
This analysis of reports submitted to the Pennsylvania Patient Safety Authority discusses why wrong … https://psnet.ahrq.gov/issue/wrong-patient-medication-errors-analysis-event-reports-pennsylvania-and-strategies-prevention … https://psnet.ahrq.gov/issue/wrong-patient-medication-errors-analysis-event-reports-pennsylvania-and-strategies-prevention
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psnet.ahrq.gov/issue/prevention-3-never-events-operating-room-fires-gossypiboma-and-wrong-site-surgery
February 10, 2012 - Review
Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site … Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery. … Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery. … May 25, 2022
Wrong-site surgery in California, 2007–2014. … June 15, 2016
Wrong-site surgery, retained surgical items, and surgical fires: a systematic
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psnet.ahrq.gov/node/48193/psn-pdf
August 28, 2019 - Automated detection of wrong-drug prescribing errors. … Automated detection of wrong-drug prescribing errors. … https://psnet.ahrq.gov/issue/automated-detection-wrong-drug-prescribing-errors
Look-alike and sound-alike … https://psnet.ahrq.gov/issue/automated-detection-wrong-drug-prescribing-errors
https://psnet.ahrq.gov
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psnet.ahrq.gov/node/43819/psn-pdf
July 16, 2015 - Intercepting wrong-patient orders in a computerized
provider order entry system. … Intercepting wrong-patient orders in a computerized provider
order entry system. … https://psnet.ahrq.gov/issue/intercepting-wrong-patient-orders-computerized-provider-order-entry-system … A forcing function that
mandated correct patient identification resulted in a moderate decrease in wrong-patient … https://psnet.ahrq.gov/issue/intercepting-wrong-patient-orders-computerized-provider-order-entry-system
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psnet.ahrq.gov/node/43842/psn-pdf
January 28, 2015 - Should health care providers be forced to apologise after
things go wrong? … Should health care providers be forced to apologise after things go
wrong? … https://psnet.ahrq.gov/issue/should-health-care-providers-be-forced-apologise-after-things-go-wrong … https://psnet.ahrq.gov/issue/should-health-care-providers-be-forced-apologise-after-things-go-wrong
https … apology-errors-whose-responsibility
https://psnet.ahrq.gov/issue/more-words-patients-views-apology-and-disclosure-when-things-go-wrong-cancer-care
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psnet.ahrq.gov/node/41952/psn-pdf
January 16, 2013 - Prevention of a wrong-location misadministration through
the use of an intradepartmental incident learning … Prevention of a wrong-location misadministration through the use of an
intradepartmental incident learning … https://psnet.ahrq.gov/issue/prevention-wrong-location-misadministration-through-use-intradepartmental … https://psnet.ahrq.gov/issue/prevention-wrong-location-misadministration-through-use-intradepartmental-incident-learning … https://psnet.ahrq.gov/issue/prevention-wrong-location-misadministration-through-use-intradepartmental-incident-learning
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psnet.ahrq.gov/issue/dtap-tdap-mix-ups-now-affecting-hundreds-patients
June 10, 2018 - June 16, 2019
Oops, sorry, wrong patient! … Site, Wrong Procedure and Wrong Person Surgery. … February 9, 2011
The wrong foot, and other tales of surgical error. … February 8, 2011
Wrong-site craniotomy: analysis of 35 cases and systems for prevention … July 23, 2010
Avoiding wrong site surgery: a systematic review.
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psnet.ahrq.gov/node/40132/psn-pdf
May 25, 2011 - Information needs in operating room teams: what is right,
what is wrong, and what is needed? … Information needs in operating room teams: what is right, what is
wrong, and what is needed? … https://psnet.ahrq.gov/issue/information-needs-operating-room-teams-what-right-what-wrong-and-what- … https://psnet.ahrq.gov/issue/information-needs-operating-room-teams-what-right-what-wrong-and-what-needed … https://psnet.ahrq.gov/issue/information-needs-operating-room-teams-what-right-what-wrong-and-what-needed
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psnet.ahrq.gov/node/45430/psn-pdf
September 28, 2016 - Understanding and responding when things go wrong:
key principles for primary care educators. … Understanding and responding when things go wrong: key principles for
primary care educators. … https://psnet.ahrq.gov/issue/understanding-and-responding-when-things-go-wrong-key-principles-primary … https://psnet.ahrq.gov/issue/understanding-and-responding-when-things-go-wrong-key-principles-primary-care-educators … https://psnet.ahrq.gov/issue/understanding-and-responding-when-things-go-wrong-key-principles-primary-care-educators
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psnet.ahrq.gov/node/43294/psn-pdf
April 25, 2016 - The right and wrong way to talk to patients about adverse
events. … The right and wrong way to talk to patients about adverse events. … https://psnet.ahrq.gov/issue/right-and-wrong-way-talk-patients-about-adverse-events
Apology laws have … https://psnet.ahrq.gov/issue/right-and-wrong-way-talk-patients-about-adverse-events
https://psnet.ahrq.gov … narrative-review-do-state-laws-make-it-easier-say-im-sorry
https://psnet.ahrq.gov/issue/when-things-go-wrong-responding-adverse-events
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psnet.ahrq.gov/node/44394/psn-pdf
August 24, 2018 - Getting the wrong person's medicine at the pharmacy:
easy steps consumers can take to help eliminate … https://psnet.ahrq.gov/issue/getting-wrong-persons-medicine-pharmacy-easy-steps-consumers-can-take- … newsletter article
describes how correctly completed medication orders can inadvertently be given to the wrong … https://psnet.ahrq.gov/issue/getting-wrong-persons-medicine-pharmacy-easy-steps-consumers-can-take-help-eliminate-these … https://psnet.ahrq.gov/issue/getting-wrong-persons-medicine-pharmacy-easy-steps-consumers-can-take-help-eliminate-these
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psnet.ahrq.gov/node/43368/psn-pdf
October 01, 2014 - Operating room briefings or time-outs are mandated by The Joint Commission as a strategy to prevent
wrong-site … improving-safety-and-quality-care-enhanced-teamwork-through-operating-room-briefings
https://psnet.ahrq.gov/issue/operating-room-briefings-and-wrong-site-surgery … https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery
https://psnet.ahrq.gov
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psnet.ahrq.gov/node/38332/psn-pdf
January 14, 2009 - periodic audits and feedback to increase
compliance with patient identification in the prevention of wrong-patient … and wrong-site surgery. … A related commentary [see link below] discusses the broader context of efforts to
eliminate wrong-site … verifying-patient-identity-and-site-surgery-improving-compliance-protocol-audit-and-feedback
https://psnet.ahrq.gov/issue/wrong-patient … https://psnet.ahrq.gov/issue/incidence-patterns-and-prevention-wrong-site-surgery
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psnet.ahrq.gov/node/50681/psn-pdf
November 20, 2019 - The wrong goodbye.
November 20, 2019
Sexton J, Schweber N. ProPublica. October 31, 2019. … https://psnet.ahrq.gov/issue/wrong-goodbye
Misidentification of patients can cause harm. … https://psnet.ahrq.gov/issue/wrong-goodbye
https://psnet.ahrq.gov/web-mm/mistaken-identity
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psnet.ahrq.gov/node/41958/psn-pdf
April 17, 2013 - https://psnet.ahrq.gov/issue/surgical-never-events-united-states
More than a decade ago, stories of wrong … An incident of wrong-site surgery is
discussed in an AHRQ WebM&M commentary. … https://psnet.ahrq.gov/issue/surgical-never-events-united-states
https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery
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psnet.ahrq.gov/node/43416/psn-pdf
August 13, 2014 - Compliance with a time-out procedure intended to
prevent wrong surgery in hospitals: results of a national … Compliance with a time-out procedure intended to prevent wrong
surgery in hospitals: results of a national … https://psnet.ahrq.gov/issue/compliance-time-out-procedure-intended-prevent-wrong-surgery-hospitals- … https://psnet.ahrq.gov/issue/compliance-time-out-procedure-intended-prevent-wrong-surgery-hospitals-results-national … https://psnet.ahrq.gov/issue/compliance-time-out-procedure-intended-prevent-wrong-surgery-hospitals-results-national
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psnet.ahrq.gov/node/50727/psn-pdf
December 11, 2019 - Your diagnosis was wrong. Could doctor bias have been
a factor?
December 11, 2019
Glicksman E. … https://psnet.ahrq.gov/issue/your-diagnosis-was-wrong-could-doctor-bias-have-been-factor
Unconscious … https://psnet.ahrq.gov/issue/your-diagnosis-was-wrong-could-doctor-bias-have-been-factor
https://psnet.ahrq.gov
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psnet.ahrq.gov/node/36945/psn-pdf
May 20, 2019 - psnet.ahrq.gov/issue/national-time-out-day
https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery
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psnet.ahrq.gov/node/37914/psn-pdf
August 06, 2008 - Hospital tells of surgery on wrong side.
August 6, 2008
Smith S. … https://psnet.ahrq.gov/issue/hospital-tells-surgery-wrong-side
This article reports on a wrong-side … https://psnet.ahrq.gov/issue/hospital-tells-surgery-wrong-side