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psnet.ahrq.gov/node/44481/psn-pdf
September 09, 2015 - When doctors get it wrong: misdiagnoses are getting a
closer look.
September 9, 2015
Olsen J. … https://psnet.ahrq.gov/issue/when-doctors-get-it-wrong-misdiagnoses-are-getting-closer-look
Diagnostic … https://psnet.ahrq.gov/issue/when-doctors-get-it-wrong-misdiagnoses-are-getting-closer-look
https://psnet.ahrq.gov
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psnet.ahrq.gov/perspective/advancing-patient-safety-through-state-reporting-systems
June 01, 2007 - Analysis of wrong-patient/wrong-site surgical errors led to development of the New York preoperative … (Go to table citation in commentary)
Surgical Events
Surgery performed on the wrong body … part
Surgery performed on the wrong patient
Wrong surgical procedure performed on a patient
Unintended … Patient death or serious disability associated with a medication error (e.g., errors involving the wrong … drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration
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psnet.ahrq.gov/issue/implementing-safety-hotlines-stamford-healths-experience-and-future-opportunities
March 23, 2011 - August 17, 2018
Experience of wrong site surgery and surgical marking practices among … August 5, 2008
Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events
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psnet.ahrq.gov/node/40474/psn-pdf
July 02, 2011 - survey-use-time-out-protocols-emergency-medicine
https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery
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psnet.ahrq.gov/node/38048/psn-pdf
October 03, 2017 - preventing-facility-pressure-ulcers-patient-safety-strategy-systematic-review
https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery
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psnet.ahrq.gov/web-mm/misidentifying-unidentified-john-doe-and-ehr
September 27, 2017 - data to the wrong patient have been opened. … And while labs and diagnostics that are erroneously linked to the wrong patient can lead to secondary … or tertiary errors such as wrong treatments based on interpreting wrong information, blood banking errors—a … May 10, 2023
Adding automation and independent dual verification to reduce wrong blood … May 29, 2019
Wrong-patient blood transfusion error: leveraging technology to overcome
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psnet.ahrq.gov/node/43232/psn-pdf
June 04, 2014 - psnet.ahrq.gov/issue/standardization-patient-safety-who-high-5s-project
https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery
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psnet.ahrq.gov/node/47275/psn-pdf
November 19, 2018 - safety-stop-valuable-addition-pediatric-universal-protocol
https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery
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psnet.ahrq.gov/web-mm/mistaken-identity
December 18, 2014 - After further investigation, the intern realized that the orthopedic team had evaluated the wrong patient—the … For example, the Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery … The wrong patient. Ann Intern Med. 2002;136:826-833. [go to PubMed] 4. Seiden SC, Barach P. … Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: are they preventable? … Universal protocol for preventing wrong site, wrong procedure, wrong person surgery.
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psnet.ahrq.gov/node/45251/psn-pdf
August 24, 2016 - 5 cataract surgeries, 5 people blinded: what went wrong?
August 24, 2016
Kowalczyk L. … https://psnet.ahrq.gov/issue/5-cataract-surgeries-5-people-blinded-what-went-wrong
Certain elements … https://psnet.ahrq.gov/issue/5-cataract-surgeries-5-people-blinded-what-went-wrong
https://psnet.ahrq.gov
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psnet.ahrq.gov/node/45019/psn-pdf
April 27, 2016 - https://psnet.ahrq.gov/primer/checklists
https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery
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psnet.ahrq.gov/node/45557/psn-pdf
October 27, 2016 - https://psnet.ahrq.gov/primer/checklists
https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery
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psnet.ahrq.gov/node/44140/psn-pdf
July 15, 2015 - Openness and Honesty When Things Go Wrong: the
Professional Duty of Candour. … https://psnet.ahrq.gov/issue/openness-and-honesty-when-things-go-wrong-professional-duty-candour
Open … https://psnet.ahrq.gov/issue/openness-and-honesty-when-things-go-wrong-professional-duty-candour
https
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psnet.ahrq.gov/node/39073/psn-pdf
February 20, 2010 - my-five-moments-hand-hygiene-user-centred-design-approach-understand-train-monitor-and-report
https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery
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psnet.ahrq.gov/node/44520/psn-pdf
September 30, 2015 - issue/quantifying-and-characterizing-adverse-events-dermatologic-surgery
https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery
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psnet.ahrq.gov/issue/systematic-workup-transfusion-reactions-reveals-passive-co-reporting-handling-errors
December 21, 2016 - Related Resources
Serious hazards of transfusion: evaluating the dangers of a wrong … October 5, 2022
Adding automation and independent dual verification to reduce wrong blood … 2022
Machine learning models outperform manual result review for the identification of wrong … December 16, 2020
WebM&M Cases
“This is the wrong patient's … : Evaluating a Near-Miss Wrong Transfusion Event
January 29, 2020
Safety incident
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psnet.ahrq.gov/issue/safety-incident-reports-associated-blood-transfusions
July 13, 2010 - July 13, 2010
Electronic patient identification for sample labeling reduces wrong blood … September 6, 2023
Serious hazards of transfusion: evaluating the dangers of a wrong patient … 2022
Machine learning models outperform manual result review for the identification of wrong … December 16, 2020
WebM&M Cases
“This is the wrong patient's … : Evaluating a Near-Miss Wrong Transfusion Event
January 29, 2020
Hospital-based
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psnet.ahrq.gov/issue/introduction-mobile-adverse-event-reporting-system-associated-participation-adverse-event
July 03, 2016 - April 12, 2011
Patients use an internet technology to report when things go wrong. … January 18, 2011
Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events
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psnet.ahrq.gov/issue/patient-misidentifications-caused-errors-standard-barcode-technology
June 13, 2012 - February 1, 2023
Adding automation and independent dual verification to reduce wrong … Development and implementation of a subcutaneous insulin pen label bar code scanning protocol to prevent wrong-patient … May 29, 2019
Wrong-patient blood transfusion error: leveraging technology to overcome … March 20, 2019
Electronic patient identification for sample labeling reduces wrong blood … See More About The Topic
Quality and Safety Professionals
Information Professionals
Wrong
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psnet.ahrq.gov/issue/patients-perspectives-quality-and-patient-safety-failures-lessons-learned-inquiry
September 28, 2017 - May 24, 2023
Insurance claims for wrong-side, wrong-organ, wrong-procedure, or wrong-person … 2020
Assessment of the implementation of a national patient safety alert to reduce wrong