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Total Results: 4,259 records

Showing results for "wrong".

381. A chemotherapy incident reporting and improvement system. | PSNet
     psnet.ahrq.gov/issue/chemotherapy-incident-reporting-and-improvement-system
     November 16, 2022 - March 28, 2011 Patients use an internet technology to report when things go wrong. … December 15, 2010 Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events

382. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37492/psn-pdf
     March 18, 2010 - Insight into preventing wrong-site surgery. … https://psnet.ahrq.gov/issue/insight-preventing-wrong-site-surgery This article summarizes a state-level … analysis that used site visits along with near miss and error reports to evaluate wrong-site surgeries … https://psnet.ahrq.gov/issue/insight-preventing-wrong-site-surgery

383. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37973/psn-pdf
     November 28, 2016 - When it's surgery, don't get it wrong. November 28, 2016 Grant T. … https://psnet.ahrq.gov/issue/when-its-surgery-dont-get-it-wrong This article reports on a wrong-sided … https://psnet.ahrq.gov/issue/when-its-surgery-dont-get-it-wrong https://psnet.ahrq.gov//#nearmiss

384. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39906/psn-pdf
     July 08, 2013 - issue/safe-site-invasive-procedure-non-operating-room This protocol is designed to protect against wrong-site … /psnet.ahrq.gov/issue/safe-site-invasive-procedure-non-operating-room https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery

385. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44238/psn-pdf
     November 03, 2015 - https://psnet.ahrq.gov/issue/use-temporary-names-newborns-and-associated-risks Wrong-patient errors … temporary names if they don't have a name immediately after birth, and this may increase the rates of wrong-patient … that implementing specific first names that incorporated the mother's name reduced the incidence of wrong-patient … psnet.ahrq.gov/issue/use-temporary-names-newborns-and-associated-risks https://psnet.ahrq.gov/issue/wrong-patient … https://psnet.ahrq.gov/primer/never-events https://psnet.ahrq.gov/issue/understanding-and-preventing-wrong-patient-electronic-orders-randomized-controlled-trial

386. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40194/psn-pdf
     June 20, 2011 - What happens when things go wrong? June 20, 2011 Brandom BW, Callahan P, Micalizzi DA. … What happens when things go wrong? … https://psnet.ahrq.gov/issue/what-happens-when-things-go-wrong This commentary reveals a personal story … https://psnet.ahrq.gov/issue/what-happens-when-things-go-wrong

387. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37009/psn-pdf
     March 18, 2010 - Doing the "right" things to correct wrong-site surgery. … March 18, 2010 Patient Safety Advisory https://psnet.ahrq.gov/issue/doing-right-things-correct-wrong-site-surgery … This article discusses reports of wrong-site surgery submitted to the PA-PSRS, compares them with results … https://psnet.ahrq.gov/issue/doing-right-things-correct-wrong-site-surgery https://psnet.ahrq.gov/issue

388. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44180/psn-pdf
     June 21, 2015 - intended to refer to adverse events that were both clinically devastating and largely preventable—such as wrong-site … A case of a wrong-site surgery is discussed in a recent AHRQ WebM&M commentary. … primer/never-events https://psnet.ahrq.gov/issue/national-quality-forum https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery

389. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37990/psn-pdf
     August 13, 2008 - Most surgery in wrong spot done on spine: 11 such cases found in state since 2006. … https://psnet.ahrq.gov/issue/most-surgery-wrong-spot-done-spine-11-such-cases-found-state-2006 This … article reports on the incidence of wrong site surgeries in Massachusetts and describes complex factors … https://psnet.ahrq.gov/issue/most-surgery-wrong-spot-done-spine-11-such-cases-found-state-2006

390. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/854639/psn-pdf
     October 18, 2023 - Right Kind of Wrong: Why Learning to Fail can Teach us to Thrive. October 18, 2023 Edmondson A. … https://psnet.ahrq.gov/issue/right-kind-wrong-why-learning-fail-can-teach-us-thrive Despite the harm … https://psnet.ahrq.gov/issue/right-kind-wrong-why-learning-fail-can-teach-us-thrive https://psnet.ahrq.gov

391. Litigation related to inadequate anaesthesia: an analysis of claims against the NHS in England 1995-2007. | PSNet
     psnet.ahrq.gov/issue/litigation-related-inadequate-anaesthesia-analysis-claims-against-nhs-england-1995-2007
     November 16, 2022 - 2014 Assessment of the implementation of a national patient safety alert to reduce wrong … February 15, 2023 View More Related Resources Insurance claims for wrong-side … , wrong-organ, wrong-procedure, or wrong-person surgical errors: a retrospective study for 10 years.

392. Representative case series from public hospital admissions 1998 II: surgical adverse events. | PSNet
     psnet.ahrq.gov/issue/representative-case-series-public-hospital-admissions-1998-ii-surgical-adverse-events
     June 07, 2023 - December 22, 2010 Operating room briefings and wrong-site surgery. … June 22, 2009 Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events

393. The 5th anniversary of the "Universal Protocol": pitfalls and pearls revisited. | PSNet
     psnet.ahrq.gov/issue/5th-anniversary-universal-protocol-pitfalls-and-pearls-revisited
     December 21, 2014 - and wrong-patient procedures in the Universal Protocol era: analysis of a prospective database of physician … Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong … Site, Wrong Procedure and Wrong Person Surgery. … February 9, 2011 The wrong foot, and other tales of surgical error. … September 24, 2008 Incidence, patterns, and prevention of wrong-site surgery.

394. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41698/psn-pdf
     November 27, 2012 - on a patient's legs, this article reveals how hospital protocol and medical record review prevented wrong-site … https://psnet.ahrq.gov/issue/duplication-surgical-site-marking https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery

395. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39381/psn-pdf
     March 17, 2010 - Getting it right when things go wrong. March 17, 2010 Pettker CM, Funai EF. … Getting it right when things go wrong. JAMA. 2010;303(10):977-8. doi:10.1001/jama.2010.256. … https://psnet.ahrq.gov/issue/getting-it-right-when-things-go-wrong This brief commentary discusses the … https://psnet.ahrq.gov/issue/getting-it-right-when-things-go-wrong https://psnet.ahrq.gov/issue/balancing-no-blame-accountability-patient-safety

396. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74733/psn-pdf
     February 02, 2022 - This tool outlines a three-step process for minimizing the occurrence of wrong-side peripheral nerve … https://psnet.ahrq.gov/issue/prep-stop-block https://psnet.ahrq.gov/issue/wrong-site-nerve-blocks-systematic-literature-review-guide-principles-prevention … psnet.ahrq.gov/issue/how-change-hospital-policy-saved-thousands-lives https://psnet.ahrq.gov/web-mm/wrong-side-bedside-paravertebral-block-preventing-preventable

397. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/849139/psn-pdf
     May 17, 2023 - How the opioid backlash went wrong. May 17, 2023 Freedman DH.  Newsweek Magazine. … https://psnet.ahrq.gov/issue/how-opioid-backlash-went-wrong The unintended consequences of reductions … https://psnet.ahrq.gov/issue/how-opioid-backlash-went-wrong https://psnet.ahrq.gov/issue/intended-and-unintended-consequences-changes-opioid-prescribing-practices-postsurgical-acute

398. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60976/psn-pdf
     September 30, 2020 - Dangerous wrong-route errors with tranexamic acid. … https://psnet.ahrq.gov/issue/dangerous-wrong-route-errors-tranexamic-acid This announcement highlights … https://psnet.ahrq.gov/issue/dangerous-wrong-route-errors-tranexamic-acid https://psnet.ahrq.gov/issue

399. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37436/psn-pdf
     January 01, 2013 - Ventilator-associated pneumonia—the wrong quality measure for benchmarking. … Ventilator-associated pneumonia—the wrong quality measure for benchmarking. … https://psnet.ahrq.gov/issue/ventilator-associated-pneumonia-wrong-quality-measure-benchmarking This … https://psnet.ahrq.gov/issue/ventilator-associated-pneumonia-wrong-quality-measure-benchmarking

400. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39778/psn-pdf
     August 18, 2010 - The institution did not experience any wrong-site surgeries during that time. … eight-year-experience-neurosurgical-checklist https://psnet.ahrq.gov/primer/checklists https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery