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Total Results: 4,259 records

Showing results for "wrong".

3661. Primary Workaround, Secondary Complication | PSNet
      psnet.ahrq.gov/web-mm/primary-workaround-secondary-complication
      January 24, 2018 - can cause tension for those who use them because their use may risk retribution should something go wrong … Laparoscopic Surgery January 1, 2015 WebM&M Cases Wrong

3662. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33649/psn-pdf
      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

3663. WebM&M: Case Studies | PSNet
      psnet.ahrq.gov/webmm-case-studies
      March 25, 2025 - Reporting (30) Institutional Reporting (6) Never Events (3) Wrong … 8) Fatigue and Sleep Deprivation (2) Identification Errors (33) Wrong … Intraoperative Complications (39) Retained Surgical Instruments and Sponges (5) Wrong-Site

3664. In Conversation with... Charles Ornstein | PSNet
      psnet.ahrq.gov/perspective/conversation-charles-ornstein
      October 01, 2009 - forms, you start seeing the range of things that happen in health facilities and how things can go wrong … of computerized prescribing and decision support Willie King, a 51-year-old diabetic, has the wrong … leg amputated University Community Hospital, Tampa, FL 1995 New focus on wrong-site surgery, ultimately … Jesica Santillan, a 17-year-old girl from Mexico, dies after receiving a heart-lung transplant of the wrong

3665. The Media: An Essential, If Sometimes Arbitrary, Promoter of Patient Safety | PSNet
      psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety
      October 01, 2009 - of computerized prescribing and decision support Willie King, a 51-year-old diabetic, has the wrong … leg amputated University Community Hospital, Tampa, FL 1995 New focus on wrong-site surgery, ultimately … Jesica Santillan, a 17-year-old girl from Mexico, dies after receiving a heart-lung transplant of the wrong … forms, you start seeing the range of things that happen in health facilities and how things can go wrong

3666. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.218_slideshow.ppt
      May 01, 2010 - celebrate acts by people who succeeded despite the organization and its complexity When things go wrong

3667. Dependence vs. Pain | PSNet
      psnet.ahrq.gov/web-mm/dependence-vs-pain
      October 30, 2019 - Association of display of patient photographs in the electronic health record with wrong-patient … Effect of restriction of the number of concurrently open records in an electronic health record on wrong-patient … the Presentation April 1, 2015 WebM&M Cases Wrong

3668. In Conversation with...Atul Gawande, MD, MA, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-withatul-gawande-md-ma-mph
      September 01, 2007 - In the story you mentioned from the book, the resident thought there was something wrong with this elderly … There's a saying about surgeons that I love, "Sometimes wrong, never in doubt." … prevent medication errors and trying to find the correct side of the body so you didn't chop off the wrong

3669. Spotlight: Mistaken Attribution, Diagnostic Misstep | PSNet
      psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
      July 01, 2011 - For example, medication errors (such as administering the wrong drug, at the wrong dose, or at the wrong

3670. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865373/psn-pdf
      March 27, 2024 - Afterwards, people will say that the AI algorithm was wrong, yet it actually conveyed the clinical impact … It’s fine if it suggests the wrong movie for me, but what if it gets it wrong when it comes to my healthcare

3671. In Conversation With… Sigall K. Bell, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-sigall-k-bell-md
      February 26, 2025 - I started thinking about how to improve communication when things go wrong, cowrote the facilitator's … open and honest communication, and organizational culture to help patients and families when things go wrong … I started off in patient safety thinking about how we could do a better job when things go wrong.

3672. Round-Trip Service | PSNet
      psnet.ahrq.gov/web-mm/round-trip-service
      April 26, 2023 - September 1, 2003 WebM&M Cases Slow Down: Right Drug, Wrong … 1, 2006 WebM&M Cases Root Cause Analysis Gone Wrong

3673. Poorly Advanced Directives | PSNet
      psnet.ahrq.gov/web-mm/poorly-advanced-directives
      August 01, 2018 - Transport February 1, 2019 WebM&M Cases The Wrong

3674. The Missing Suction Tip | PSNet
      psnet.ahrq.gov/web-mm/missing-suction-tip
      January 01, 2006 - What went wrong in this case? … Analysis of this case in light of this experience provides additional insight into what went wrong.

3675. The Dropped "No" | PSNet
      psnet.ahrq.gov/web-mm/dropped-no
      October 30, 2019 - lead to unnecessary invasive procedures, failure to administer needed treatments, or surgery on the wrong … side or at the wrong level.

3676. Liver Failure After Chemotherapy: Did We Forget Something? | PSNet
      psnet.ahrq.gov/web-mm/liver-failure-after-chemotherapy-did-we-forget-something
      May 01, 2019 - Borderline December 1, 2006 WebM&M Cases The Wrong

3677. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49470/psn-pdf
      December 01, 2004 - medication profiles, going over follow-up plans, and providing patients options for what to do if things go wrong … Lastly, they need to have a back-up plan for when things go wrong.

3678. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33662/psn-pdf
      January 01, 2008 - For example, how many wrong-site, wrong-side surgeries did they have, and then come up with the policies

3679. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60173/psn-pdf
      March 30, 2020 - For example, with regards to retained foreign bodies and wrong site surgeries, I remember thinking when … For example, do we need to still look at wrong site surgery?

3680. A Mistaken Dose of Naloxone  | PSNet
      psnet.ahrq.gov/web-mm/mistaken-dose-naloxone
      March 21, 2009 - WebM&M Cases Medication Errors in Retail Pharmacies: Wrong … Patient, Wrong Instructions.