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Total Results: 4,259 records

Showing results for "wrong".

3621. In Conversation With… Sidney Dekker, MA, MSc, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-sidney-dekker-ma-msc-phd
      February 26, 2025 - We have systems thinking on the one hand: If you want to understand why things go wrong you've got to … to find ways in which we can actually rebalance this attribution of responsibility for why things go wrong … And I think this is where even the ancient Greeks may have gotten it wrong.

3622. Multifactorial Medication Mishap | PSNet
      psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
      September 01, 2016 - Although it may seem that the only error in this case was the nurse giving the wrong amount of medication … example, in a root cause analysis (RCA) of a fatal medication error in which a nurse administered the wrong … Related Resources From the Same Author(s) WebM&M Cases Wrong-Time

3623. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33867/psn-pdf
      October 01, 2018 - Unfortunately, we do sometimes have people choosing the wrong item off a drop-down list, particularly … Then immediately they realize they've selected the wrong drug off the drop-down list. … risk-models-improve-safety-dispensing-high-alert-medications-community-pharmacies https://psnet.ahrq.gov/issue/getting-wrong-persons-medicine-pharmacy-easy-steps-consumers-can-take-help-eliminate-these

3624. A Troubling Amine | PSNet
      psnet.ahrq.gov/web-mm/troubling-amine
      September 01, 2003 - certain drug names and indications for antiretrovirals and insulin secretagogues successfully prevented wrong … 2006 WebM&M Cases Looking for Meds in All the Wrong

3625. Safety in the Retail Pharmacy | PSNet
      psnet.ahrq.gov/perspective/safety-retail-pharmacy
      May 11, 2016 - December 9, 2020 Wrong drug and wrong dose dispensing errors identified in pharmacist

3626. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49397/psn-pdf
      May 01, 2003 - They performed the wrong procedure because they oversimplified this patient’s complex presentation by … focusing on familiar findings, which guided them to the wrong diagnosis--an intention error.

3627. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49436/psn-pdf
      February 26, 2004 - M thus never received the wrong blood. This case represents a very serious near miss. … psnet.ahrq.gov/web-mm/transfusion-slip https://psnet.ahrq.gov//#references Miscollected blood samples—the wrong

3628. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49423/psn-pdf
      November 01, 2003 - What went wrong in this case? … Analysis of this case in light of this experience provides additional insight into what went wrong.

3629. Workaround Error | PSNet
      psnet.ahrq.gov/web-mm/workaround-error
      October 30, 2024 - The risk of pulling the wrong medication out of the medication cart is also increased if the patient … December 30, 2014 WebM&M Cases Wrong Route for Nutrients

3630. Patient Safety in the United Kingdom: Evolution and Progress | PSNet
      psnet.ahrq.gov/perspective/patient-safety-united-kingdom-evolution-and-progress
      May 01, 2007 - It described the NHS as having an old-fashioned approach to learning lessons when things go wrong and … must do's" to improve patient safety: Unified mechanisms for reporting and analysis when things go wrong … opinion surveys seem to tell us that when somebody suffers harm, their motive is to find out what went wrong … about whether to wait for a full-blown incident or whether there are pointers to things that might go wrong

3631. In Conversation with...Sir Liam Donaldson, MD, MSc | PSNet
      psnet.ahrq.gov/perspective/conversation-withsir-liam-donaldson-md-msc
      May 01, 2007 - opinion surveys seem to tell us that when somebody suffers harm, their motive is to find out what went wrong … about whether to wait for a full-blown incident or whether there are pointers to things that might go wrong … It described the NHS as having an old-fashioned approach to learning lessons when things go wrong and … must do's" to improve patient safety: Unified mechanisms for reporting and analysis when things go wrong

3632. In Conversation with...James P. Bagian, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-withjames-p-bagian-md
      September 01, 2006 - among the internal VA doctors, to think it is command and control from my lips to their ears would be wrong … RW: So let's say, at my place in Des Moines, my second day on the job somebody operates on the wrong … for instance, to learn that 44% of incorrect surgeries were right-left mix-ups, versus 36% being the wrong … include increasing disclosure of adverse events; root cause analyses; and programs for preventing falls, wrong-site … important approach is to learn from minor errors and near-miss incidents, such as when a doctor records the wrong

3633. Effect of a postdischarge virtual ward on readmission or death for high-risk patients: a randomized clinical trial. | PSNet
      psnet.ahrq.gov/issue/effect-postdischarge-virtual-ward-readmission-or-death-high-risk-patients-randomized-clinical
      October 31, 2011 - September 28, 2016 Frequency and clinical importance of pages sent to the wrong physician

3634. Cultural Dimensions of Depression | PSNet
      psnet.ahrq.gov/web-mm/cultural-dimensions-depression
      September 01, 2018 - What was the patient's concept of what was wrong with him? … medical evaluation without such a foundation may signal to the patient that something is seriously wrong

3635. Patient Safety in the Physician Office Setting | PSNet
      psnet.ahrq.gov/perspective/patient-safety-physician-office-setting
      November 04, 2015 - physicians and their staffs, it appears that practices more commonly prescribe the right drug at the wrong … dose, timing, or administration than they prescribe the wrong drug (or forget to prescribe a drug).(

3636. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33650/psn-pdf
      May 01, 2007 - It described the NHS as having an old- fashioned approach to learning lessons when things go wrong and … must do's" to improve patient safety: Unified mechanisms for reporting and analysis when things go wrong

3637. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49637/psn-pdf
      October 01, 2011 - lead to unnecessary invasive procedures, failure to administer needed treatments, or surgery on the wrong … side or at the wrong level.

3638. Not All Headaches are Due to Migraine: Red Flags, Don’t Miss Diagnoses, and Diagnostic Pitfalls | PSNet
      psnet.ahrq.gov/web-mm/not-all-headaches-are-due-migraine-red-flags-dont-miss-diagnoses-and-diagnostic-pitfalls
      February 17, 2021 - ” 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

3639. Missing ECG and Missed Diagnosis Lead to Dangerous Delay | PSNet
      psnet.ahrq.gov/web-mm/missing-ecg-and-missed-diagnosis-lead-dangerous-delay
      March 01, 2015 - O'Connor, MD, MPH Virtually everything that could have gone wrong with this case did go wrong.

3640. Bowel Prep | PSNet
      psnet.ahrq.gov/web-mm/bowel-prep
      March 01, 2017 - Hidden Mystery March 1, 2005 WebM&M Cases Wrong-Time … Forgotten Tube February 1, 2014 WebM&M Cases Wrong