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Total Results: 4,259 records

Showing results for "wrong".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49849/psn-pdf
    January 01, 2019 - For example, medication errors (such as administering the wrong drug, at the wrong dose, or at the wrong

  2. In Conversation With... Elsabeth Kalenderian, DDS, MPH, PhD and Muhammad F. Walji, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-elsabeth-kalenderian-dds-mph-phd-and-muhammad-f-walji-phd
    December 22, 2020 - But there are also things like wrong tooth extraction, which people mentioned but don’t seem to come … The most frequently cited AEs were aspiration/ingestion, wrong-site, wrong procedure, wrong patient errors

  3. Adverse Events in Dentistry | PSNet

    psnet.ahrq.gov/perspective/adverse-events-dentistry
    December 22, 2020 - The most frequently cited AEs were aspiration/ingestion, wrong-site, wrong procedure, wrong patient errors … But there are also things like wrong tooth extraction, which people mentioned but don’t seem to come

  4. In Conversation With… Mark Graban, MS, MBA | PSNet

    psnet.ahrq.gov/perspective/conversation-mark-graban-ms-mba
    January 01, 2015 - times, people talk about culture change without having the hard conversations about what exactly is wrong … admitting mistakes, looking at the process and systems, and taking a different approach when things go wrong … around in the workplace and everyone freaks out because they think somebody must have died, or what went wrong—why … It's both encouraging and frustrating sometimes that what tends to go wrong in health care is very preventable

  5. Innovation and Lean Thinking: Mutually Supportive Partners in the Transformation of Health Care | PSNet

    psnet.ahrq.gov/perspective/innovation-and-lean-thinking-mutually-supportive-partners-transformation-health-care
    January 01, 2015 - times, people talk about culture change without having the hard conversations about what exactly is wrong … admitting mistakes, looking at the process and systems, and taking a different approach when things go wrong … around in the workplace and everyone freaks out because they think somebody must have died, or what went wrong—why … It's both encouraging and frustrating sometimes that what tends to go wrong in health care is very preventable

  6. What Was in Those Platelets? | PSNet

    psnet.ahrq.gov/web-mm/what-was-those-platelets
    August 28, 2024 - is approximately 1:200,000.( 5,6 ) Comparatively, the risk of receiving ABO-incompatible blood (the wrong … Related Resources WebM&M Cases “This is the wrong … : Evaluating a Near-Miss Wrong Transfusion Event January 29, 2020

  7. Unseen Perils of Urinary Catheters | PSNet

    psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters
    January 31, 2024 - WebM&M Cases From Possible to Probable to Sure to Wrong—Premature … High-Risk Transfers October 1, 2017 WebM&M Cases Wrong-Time … Unfamiliar Catheter March 1, 2013 WebM&M Cases Wrong

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867653/psn-pdf
    February 26, 2025 - We want to use RCA as an opportunity to identify things that are wrong and think deeply about how we … the processes that our staff use daily and how we can change them to ensure that they are not making wrong … We tend to think retrospectively about events that have caused harm—What did we do wrong?

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838222/psn-pdf
    September 28, 2022 - There’s a lot of steps along the way where things can go wrong. … For example, I have ordered the wrong test because I typed in the wrong thing.

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73906/psn-pdf
    October 06, 2021 - The parents proceeded to talk with each other in Spanish: “What's wrong with the baby? … were doing the car seat test that is for “safety,” but the patient thinks there's something terribly wrong … of Failure Mode and Effects Analysis to think about all the different things that possibly could go wrong

  11. Don't Use That Port: Insert a PICC | PSNet

    psnet.ahrq.gov/web-mm/dont-use-port-insert-picc
    December 22, 2018 - Getting it right when things go wrong. JAMA. 2010;303:977-978. … July 1, 2018 WebM&M Cases Right Regimen, Wrong

  12. The Dropped Lung | PSNet

    psnet.ahrq.gov/web-mm/dropped-lung
    February 06, 2012 - 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.

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50930/psn-pdf
    February 21, 2020 - patient harm.[3] These include patient receipt of the incorrect prescription (e.g., receiving the wrong … drug or the correct drug but at the wrong dosage), harmful drug-to-drug interactions, errors in the

  14. Transfusion "Slip" | PSNet

    psnet.ahrq.gov/web-mm/transfusion-slip
    June 14, 2011 - M thus never received the wrong blood. This case represents a very serious near miss. … Miscollected blood samples—the wrong blood in the tube—are a common problem in blood transfusion.

  15. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2019-12/spotlight_code_status_dec_2019_powerpoint.pdf
    January 01, 2019 - proceeding, because they lacked the ability to respond fully with resuscitation if something were to go wrong … with the procedure without changing the code status and assume the risk that, if something went wrong

  16. Risk Mitigation Using the Anesthesia Risk Alert Program: Applying a Proactive Approach With Data Review & Collaborating With a Second Practitioner | PSNet

    psnet.ahrq.gov/innovation/risk-mitigation-using-anesthesia-risk-alert-program-applying-proactive-approach-data
    February 26, 2025 - Next, examine the adverse events data to find problem areas (i.e., medication error, wrong patient identification … Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong

  17. Pharmacist Role in Patient Safety | PSNet

    psnet.ahrq.gov/perspective/pharmacist-role-patient-safety
    June 29, 2020 - patient harm. [3] These include patient receipt of the incorrect prescription (e.g., receiving the wrong … drug or the correct drug but at the wrong dosage), harmful drug-to-drug interactions, errors in the

  18. Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist Intervention | PSNet

    psnet.ahrq.gov/web-mm/correct-treatment-plan-incorrect-diagnosis-pharmacist-intervention
    May 01, 2011 - Safety Strategy October 27, 2021 WebM&M Cases Wrong-Time … Surprise Wire August 21, 2005 WebM&M Cases The Wrong

  19. Managing Ascites: Hazards of Fluid Removal | PSNet

    psnet.ahrq.gov/web-mm/managing-ascites-hazards-fluid-removal
    June 01, 2018 - That said, it would not be considered wrong to treat the infection and leave the ascitic fluid in place … 1, 2010 WebM&M Cases Good Night's Sleep Gone Wrong

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866848/psn-pdf
    September 25, 2024 - , quickly, and efficiently, but it's not the kind of thing where you can say, “Zero things will go wrong … things that we have to do to try to make complex care safe, and we can know where the process may go wrong
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