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Total Results: 4,259 records

Showing results for "wrong".

  1. Continuing Education | PSNet

    psnet.ahrq.gov/continuing-education
    February 26, 2025 - (3) Fatigue and Sleep Deprivation (1) Identification Errors (4) Wrong … Intraoperative Complications (11) Retained Surgical Instruments and Sponges (2) Wrong-Site

  2. The Unhappy Patient Leaves Against Medical Advice. | PSNet

    psnet.ahrq.gov/web-mm/unhappy-patient-leaves-against-medical-advice
    January 31, 2024 - What is wrong with discharges against medical advice (and how to fix them). … October 1, 2013 WebM&M Cases Wrong Route for Nutrients

  3. Periodic Issue | PSNet

    psnet.ahrq.gov/periodic-issue/periodic-issue-469
    December 31, 2024 - One-quarter of incidents included two to four errors, and wrong dose or omission were the most common … Systemic defenses are required to reduce wrong dose, omission, and documentation errors.

  4. Spotlight-Slides-Wright-Schiff (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-04/spotlight-slides-wright-schiff.pdf
    January 01, 2020 - within and between systems • Issues with ease and accuracy in finding desired drug and regimen • Wrong-patient

  5. Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-dimer. | PSNet

    psnet.ahrq.gov/web-mm/fatal-oversight-misdiagnosis-nocturnal-chest-pain-elevated-d-dimer
    May 01, 2005 - February 1, 2013 WebM&M Cases Right Regimen, Wrong … WebM&M Cases Multiple Levels Involved in Prescribing the Wrong

  6. Delayed Recognition of a Positive Blood Culture | PSNet

    psnet.ahrq.gov/web-mm/delayed-recognition-positive-blood-culture
    January 29, 2020 - Resources From the Same Author(s) WebM&M Cases “This is the wrong … : Evaluating a Near-Miss Wrong Transfusion Event January 29, 2020

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33736/psn-pdf
    September 01, 2012 - being able to observe your patients, assess them, anticipate how they're doing and what could be going wrong … predictably, as people are presented with quality information, the first reaction is "your data are wrong

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49639/psn-pdf
    November 01, 2011 - An example would be if a nurse were to pick up the wrong syringe and inject the patient with atropine … They are free lessons about how things go wrong and how they can be fixed before someone gets hurt.

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49705/psn-pdf
    January 01, 2020 - From possible to probable to sure to wrong—premature closure and anchoring in a complicated case. … perspective/conversation-withpat-croskerry-md-phd https://psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premature-closure-and-anchoring-complicated-case

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49864/psn-pdf
    June 01, 2019 - Productive feedback—talking about something really right or really wrong—can lead to useful insights … and provides some confidence that when something is really wrong in the future, it is easier to say

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49633/psn-pdf
    September 01, 2011 - Wrong route for nutrients. AHRQ WebM&M [serial online]. July 2008. [Available at] 13. … NHQIMDS30TrainingMaterials.asp https://psnet.ahrq.gov/web-mm/forgotten-turn https://psnet.ahrq.gov/web-mm/wrong-route-nutrients

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49699/psn-pdf
    February 01, 2014 - 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

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73302/psn-pdf
    May 26, 2021 - I mean, we all believe in the do no harm [principle], but if we calculate the medication the wrong way … to let them feel comfortable coming to their office and saying, “I think I just gave a patient the wrong

  14. Discharge Fumbles | PSNet

    psnet.ahrq.gov/web-mm/discharge-fumbles
    September 09, 2009 - 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.

  15. Communication Error in a Closed ICU | PSNet

    psnet.ahrq.gov/web-mm/communication-error-closed-icu
    July 01, 2016 - March 19, 2018 WebM&M Cases Wrong Turn through Colon: … Cybersecurity and How to Maintain Patient Safety March 27, 2024 So many ways to be wrong

  16. Delay in Initiating Antibiotics Results in Fatal Error | PSNet

    psnet.ahrq.gov/web-mm/delay-initiating-antibiotics-results-fatal-error
    August 02, 2015 - February 18, 2011 WebM&M Cases A Double “Never Event”: Wrong … Patient and Wrong Side.

  17. Patient Safety: A Perspective from Office Practice | PSNet

    psnet.ahrq.gov/perspective/patient-safety-perspective-office-practice
    May 01, 2009 - medical mistakes argues that a better way to frame mistakes is to think of them as actions that "go wrong … Opening oneself to an imaginative inquiry into how things could go wrong as we do them may be a very … a better approach than that of picking out individuals and shooting them because they did something wrong

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/841467/psn-pdf
    December 14, 2022 - ability to pay, deserve equal access to the best care; non-medically necessary abortions are morally wrong … ; and, perhaps relevant to this case, it is wrong to hasten death.  … other reasons, and that this case therefore serves as an example of an “order-of-reasons" problem: the wrong

  19. In Conversation with…William B. Weeks, MD, MBA | PSNet

    psnet.ahrq.gov/perspective/conversation-withwilliam-b-weeks-md-mba
    May 01, 2009 - a better approach than that of picking out individuals and shooting them because they did something wrong … medical mistakes argues that a better way to frame mistakes is to think of them as actions that "go wrong … Opening oneself to an imaginative inquiry into how things could go wrong as we do them may be a very

  20. What Makes a Good Checklist | PSNet

    psnet.ahrq.gov/perspective/what-makes-good-checklist
    October 01, 2010 - Lack of task possession resulted in the flight attendant taking the wrong action, and the fire destroyed … Third wrong-sided brain surgery at R.I. hospital. NBCnews.com. November 27, 2007. … What we found is—I think it's no different than why we see that wrong-site surgeries haven't gone down
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