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Total Results: 1,062 records

Showing results for "wrong".

61. Assessment of incorrect surgical procedures within and outside the operating room. A follow-up study from US Veterans Health Administration medical centers. | PSNet
    psnet.ahrq.gov/issue/assessment-incorrect-surgical-procedures-within-and-outside-operating-room-follow-study-us
    October 24, 2018 - The Joint Commission and National Quality Forum both consider wrong-site, wrong-procedure, and wrong-patient … A WebM&M commentary examined an incident involving a wrong-side surgery. … April 30, 2014 Prevention of wrong-site tooth extraction: clinical guidelines. … September 20, 2011 Operating room briefings and wrong-site surgery. … July 28, 2010 Incidence and root cause analysis of wrong-site pain management procedures

62. Deficiencies in Facility Leaders' Response to Critical Surgical Events at the Michael E. DeBakey VA Medical Center in Houston, Texas. | PSNet
    psnet.ahrq.gov/issue/deficiencies-facility-leaders-response-critical-surgical-events-michael-e-debakey-va-medical
    November 29, 2023 - Wrong-site surgery and unintentionally retained surgical items are considered never events . … This report details five wrong-site surgeries and three instances of retained surgical items at one VA … Additionally, the medical center failed to fully report the provider responsible for three of the wrong-site … June 15, 2016 Wrong-site surgery, retained surgical items, and surgical fires: a systematic … 2016 Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site

63. Incorrect surgical procedures within and outside of the operating room. | PSNet
    psnet.ahrq.gov/issue/incorrect-surgical-procedures-within-and-outside-operating-room
    November 21, 2011 - Wrong-patient and wrong-site surgeries are considered never events , as they are devastating errors … December 21, 2014 Preventing wrong site, procedure, and patient events using a common … Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong … Site, Wrong Procedure and Wrong Person Surgery. … November 18, 2009 Wrong site surgery near misses and actual occurrences.

64. Incorrect surgical procedures within and outside of the operating room: a follow-up report. | PSNet
    psnet.ahrq.gov/issue/incorrect-surgical-procedures-within-and-outside-operating-room-follow-report
    April 30, 2014 - procedures in the Veterans Affairs (VA) system found an overall decline in the number of reported wrong-site … , wrong-patient, and wrong-procedure errors compared with the authors' prior study . … April 30, 2014 Preventing wrong site, procedure, and patient events using a common cause … January 4, 2012 Application of human error theory in case analysis of wrong procedures … Site, Wrong Procedure and Wrong Person Surgery.

65. Using performance improvement to enhance time-out compliance and prevent wrong-site surgery. | PSNet
    psnet.ahrq.gov/issue/using-performance-improvement-enhance-time-out-compliance-and-prevent-wrong-site-surgery
    October 06, 2021 - Commentary Using performance improvement to enhance time-out compliance and prevent wrong-site … Using performance improvement to enhance time-out compliance and prevent wrong-site surgery. … Using performance improvement to enhance time-out compliance and prevent wrong-site surgery. … Prevention February 26, 2025 Patient Safety Primers Wrong-Site … , Wrong-Procedure, and Wrong-Patient Surgery December 15, 2024 Fire safety

66. Your diagnosis was wrong. Could doctor bias have been a factor? | PSNet
    psnet.ahrq.gov/issue/your-diagnosis-was-wrong-could-doctor-bias-have-been-factor
    December 22, 2021 - Newspaper/Magazine Article Your diagnosis was wrong. … Citation Text: Your diagnosis was wrong. Could doctor bias have been a factor? Glicksman E. … URL Cite Citation Citation Text: Your diagnosis was wrong … December 2, 2015 When doctors get it wrong: misdiagnoses are getting a closer look.

67. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/847733/psn-pdf
    March 16, 2025 - This guidance shares evidence-based steps to address problems such as wrong patient errors and lack … pharmacists-reducing-medication-risk-medical-outpatient-clinics-retrospective-study-18 https://psnet.ahrq.gov/web-mm/medication-errors-retail-pharmacies-wrong-patient-wrong-instructions … https://psnet.ahrq.gov/web-mm/medication-errors-retail-pharmacies-wrong-patient-wrong-instructions

68. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/837594/psn-pdf
    June 29, 2022 - Machine learning models outperform manual result review for the identification of wrong blood in tube … Machine learning models outperform manual result review for the identification of wrong blood in tube … https://psnet.ahrq.gov/issue/machine-learning-models-outperform-manual-result-review-identification- wrong-blood-tube … Wrong blood in tube (WBIT) errors can result in serious diagnostic and treatment errors, but may go … https://psnet.ahrq.gov/issue/machine-learning-models-outperform-manual-result-review-identification-wrong-blood-tube

69. High-risk medications in hospitalized elderly adults: are we making it easy to do the wrong thing? | PSNet
    psnet.ahrq.gov/issue/high-risk-medications-hospitalized-elderly-adults-are-we-making-it-easy-do-wrong-thing
    May 18, 2022 - High-risk medications in hospitalized elderly adults: are we making it easy to do the wrong … High-Risk Medications in Hospitalized Elderly Adults: Are We Making It Easy to Do the Wrong Thing? … High-Risk Medications in Hospitalized Elderly Adults: Are We Making It Easy to Do the Wrong Thing? … May 18, 2022 Evaluating serial strategies for preventing wrong-patient orders in the … March 22, 2017 Risk of wrong-patient orders among multiple vs singleton births in the

70. Effect of barcode technology on medication preparation safety: a quasi-experimental study. | PSNet
    psnet.ahrq.gov/issue/effect-barcode-technology-medication-preparation-safety-quasi-experimental-study
    December 01, 2021 - Use of BCMA decreased wrong medication and wrong dosage errors, and wrong patient, wrong form, and

71. Variation in surgical time-out and site marking within pediatric otolaryngology. | PSNet
    psnet.ahrq.gov/issue/variation-surgical-time-out-and-site-marking-within-pediatric-otolaryngology
    October 27, 2010 - March 29, 2023 Insurance claims for wrong-side, wrong-organ, wrong-procedure, or … wrong-person surgical errors: a retrospective study for 10 years. … February 8, 2023 When it's surgery, don't get it wrong. … November 28, 2016 Wrong-site and wrong-patient procedures in the Universal Protocol era … Site, Wrong Procedure and Wrong Person Surgery.

72. Identifying a list of healthcare 'never events' to effect system change: a systematic review and narrative synthesis. | PSNet
    psnet.ahrq.gov/issue/identifying-list-healthcare-never-events-effect-system-change-systematic-review-and-narrative
    April 24, 2019 - The most frequent never events were wrong site or wrong patient surgery, wrong surgical procedure , … Patient safety in marginalised groups: a narrative scoping review March 4, 2020 Wrong-site

73. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/851189/psn-pdf
    July 05, 2023 - So many ways to be wrong: completeness and accuracy in a prospective study of OR-to-ICU handoff standardization … So many ways to be wrong: completeness and accuracy in a prospective study of OR-to-ICU handoff standardization … https://psnet.ahrq.gov/issue/so-many-ways-be-wrong-completeness-and-accuracy-prospective-study-or- icu-handoff … https://psnet.ahrq.gov/issue/so-many-ways-be-wrong-completeness-and-accuracy-prospective-study-or-icu-handoff … https://psnet.ahrq.gov/issue/so-many-ways-be-wrong-completeness-and-accuracy-prospective-study-or-icu-handoff

74. Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis reports in the Veterans Health Administration. | PSNet
    psnet.ahrq.gov/issue/patient-misidentification-laboratory-medicine-qualitative-analysis-227-root-cause-analysis
    August 28, 2024 - Related Resources Serious hazards of transfusion: evaluating the dangers of a wrong … October 5, 2022 Factors associated with wrong blood in tube errors: an international … December 16, 2020 WebM&M Cases “This is the wrong patient's … : Evaluating a Near-Miss Wrong Transfusion Event January 29, 2020 Transfusion … June 2, 2019 Electronic patient identification for sample labeling reduces wrong blood

75. Randomized controlled evaluation of an insulin pen storage policy. | PSNet
    psnet.ahrq.gov/issue/randomized-controlled-evaluation-insulin-pen-storage-policy
    January 23, 2017 - This quality improvement intervention sought to decrease wrong-patient errors with insulin pens by … Development and implementation of a subcutaneous insulin pen label bar code scanning protocol to prevent wrong-patient … Effect of restriction of the number of concurrently open records in an electronic health record on wrong-patient … April 16, 2018 Intercepting wrong-patient orders in a computerized provider order entry … See More About The Topic Hospitals Health Care Providers Endocrinology Insulin Wrong

76. Right? Left? Neither! | PSNet
    psnet.ahrq.gov/web-mm/right-left-neither
    November 16, 2022 - Neither should operating on the wrong side of the right patient. … JCAHO has recommended a series of steps to prevent wrong-site, wrong-side, and wrong-person procedures … To strengthen defenses against wrong-site and wrong-patient invasive procedures, hospitals should implement … Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. … January 23, 2019 The wrong patient.

77. Medication Safety in Nursing Homes: What's Wrong and How to Fix It | PSNet
    psnet.ahrq.gov/perspective/medication-safety-nursing-homes-whats-wrong-and-how-fix-it
    August 01, 2012 - Medication Safety in Nursing Homes: What's Wrong and How to Fix It Jerry Gurwitz, MD | August 1, 2012 … Medication Safety in Nursing Homes: What's Wrong and How to Fix It. PSNet [internet]. … Medication Safety in Nursing Homes: What's Wrong and How to Fix It. PSNet [internet]. … Medication Safety in Nursing Homes: What's Wrong and How to Fix It. PSNet [internet]. … December 10, 2008 WebM&M Cases Wrong Route for Nutrients

78. Swiss Cheese Model | PSNet
    psnet.ahrq.gov/taxonomy/term/3460
    April 10, 2025 - For example, if the hazard were wrong-site surgery, slices of the cheese might include conventions for … For some serious events (e.g., operating on the wrong site or wrong person), even though the holes will

79. Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery. | PSNet
    psnet.ahrq.gov/issue/prevention-3-never-events-operating-room-fires-gossypiboma-and-wrong-site-surgery
    February 10, 2012 - Review Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site … Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery. … Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery. … May 25, 2022 Wrong-site surgery in California, 2007–2014. … June 15, 2016 Wrong-site surgery, retained surgical items, and surgical fires: a systematic

80. The public has been forgiving. But hospitals got some things wrong. | PSNet
    psnet.ahrq.gov/issue/public-has-been-forgiving-hospitals-got-some-things-wrong
    April 03, 2019 - But hospitals got some things wrong. Citation Text: Ofri D. … But hospitals got some things wrong. New York Times. 2020; May 21. … But hospitals got some things wrong. New York Times. 2020; May 21.