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Showing results for "wrong".

1. Surgical Safety: Addressing the JCAHO Goals for Reducing Wrong-site, Wrong-patient, Wrong-procedure Events (pdf file)
   www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Ludwick.pdf
   June 21, 2004 - Surgical Safety: Addressing the JCAHO Goals for Reducing Wrong-site, Wrong-patient, Wrong-procedure Events … 483 Surgical Safety: Addressing the JCAHO Goals for Reducing Wrong-site, Wrong-patient, Wrong-procedure … National patient safety goals and universal protocol for preventing wrong-site, wrong-procedure, and … wrong-person surgery. … Wrong-site surgery education tool Figure 4b.

2. Making Healthcare Safer Practices: 11. Patient Identification Errors in the Operating Room (pdf file)
   www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/patient-id-errors-1.pdf
   March 01, 2020 - , wrong- procedure, and wrong-person surgery. … , Wrong Procedure and Wrong Person Surgery. … Site, Wrong Procedure, Wrong Person Surgery Operating room The estimated rate of wrong-site … *" OR "Wrong Site Surger*" OR "Wrong-Site Surger*" OR "Surger*, Wrong-Site" OR "Surger*, Wrong Site … *" OR "Wrong Site Surger*" OR "Wrong-Site Surger*" OR "Surger*, Wrong-Site" OR "Surger*, Wrong Site

3. The New York Model: Root Cause Analysis Driving Patient Safety Initiative to Ensure Correct Surgical and Invasive Procedures (pdf file)
   www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Faltz_56.pdf
   March 27, 2008 - Introduction Wrong-patient, wrong-side, or wrong-site surgical and invasive procedures, while unusual … NYPORTS codes related to wrong-side, wrong-patient, and wrong- procedure surgery and other invasive … Surgery on the wrong side of the body, wrong site, or wrong patient led the list. … Universal protocol for preventing wrong site, wrong procedure, wrong person surgery™. … Wrong-side/wrong-site, wrong- procedure, and wrong-patient adverse events: Are they preventable?

4. Final Progress Report: Risk Models To Improve Long-Term Care Medication Safety (pdf file)
   www.ahrq.gov/sites/default/files/2024-01/higginson-report.pdf
   January 01, 2024 - drug, wrong dose, wrong resident, and omitted drug/dose. … Drug 5.9 7.0 Wrong Dose 2.8 2.8 Wrong Resident 1.0 0.7 Omission 70 70 Wrong Resident: Figure 2. … dose, wrong drug, and wrong resident. … Wrong dose 15 Wrong strength 8/4481 or .002 Wrong quantity 9/4481 or .002 Wrong Patient 1.9 0.4 … Dose Overdose 4.8 Underdose 1.9 Wrong form .3 1.8 0.2 6.2 Wrong dose 7.542 32.042 Wrong strength

5. Foundational Terminology for Diagnosis Relating to Suboptimal Processes and Outcomes | Agency for Healthcare Research and Quality
   www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-terminology7.html
   April 01, 2025 - Investigators attempted to create a meaningful taxonomy clarifying what was lacking or wrong. … Diagnostic Failure A failed process or a wrong or delayed diagnosis. … For example, a diagnosis of pneumothorax might be a wrong label (misdiagnosis) if the actual problem … Similar to the term wrong diagnosis or incorrect diagnosis . 30 Missed Diagnosis A condition that … . 3 In general, medical adverse events tend to be (but are not always) errors of commission (e.g., wrong

6. Diagnostic Error in the Testing Process | Agency for Healthcare Research and Quality
   www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-dx-stewardship4.html
   August 01, 2024 - Challenges Ahead Conclusion References Diagnostic errors include missed, delayed, and wrong … ordering urine cultures in patients without urinary tract symptoms, which can increase the risk of wrong … specimen mishandling; for instance, contamination of specimens at the time of collection can result in wrong

7. Diagnostic Error Measures: For Quality Improvement & Patient Safety Research (pdf file)
   www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/adelman-summit2016.pdf
   January 01, 2016 - Wrong Patient Errors Leading to Diagnostic Errors: 1) Order tests on wrong-patient 2) Read results of … wrong-patient 3) Communicate information to the wrong patient. … Wrong Patient Errors Leading to Diagnostic Errors xxVoluntary Reporting Chart Reviews Trigger … JAMA. 2001;285:2114-2120 Wrong-Patient Error Measures Retract-and-Reorder Tool Applied to Complete … on the wrong patient – 1 of 37 admitted patients had an order placed for them that was intended for

8. Final Progress Report: Safety Advancement in the Emergency Department (pdf file)
   www.ahrq.gov/sites/default/files/2024-01/hall2-report.pdf
   January 01, 2024 - lab(s) ordered Delay or failure to order Wrong study ordered Delay or failure to order Wrong drug … ordered Wrong dose ordered Wrong route ordered Ordered for wrong patient Ordered for wrong time … study performed Study performed on wrong patient Technical errors Wrong drug dispensed Wrong dose … dispensed Wrong route form dispensed Dispensed for wrong patient Delayed or dispensed at wrong time … drug administered Wrong dose administered Administered by wrong route Administered to wrong patient

9. Final Report: Using Risk Models To Improve Safety With Dispensing High-Alert Medications in Community Pharmacies (pdf file)
   www.ahrq.gov/sites/default/files/2024-01/cohen-report.pdf
   January 01, 2024 - dose of warfarin or the wrong insulin analog. … Wrong Insulin Analog Dispensed Due to Selecting the Wrong Drug During Data Entry Fault tree analysis. … for wrong drug errors and 9.25 per 10 million prescriptions for wrong dose errors. … Community pharmacies in the study were vulnerable to wrong drug and wrong dose data entry errors, a finding … The wrong patient.

10. New AHRQ SOPS® Diagnostic Safety Supplemental Items for Medical Offices - Schiff (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/03-new_sops_diagnostic_safety-schiff.pdf
    January 01, 2020 - test, surgery, or treatment 38% You were given wrong or unclear instructions about your follow-up … care 34% You/they were given an incorrect medication, meaning the wrong dose or wrong drug 32% … care instructions 29 Administered the wrong medication dosage 28 Received unnecessary treatment … 27 Providers gave different instructions 24 Got an infection after treatment 24 Doctor gave wrong … diagnosis” • How to even know whether diagnosis was right or wrong?

11. Final Progress Report: Pediatric Medication Safety: Analyses from the MEDMARX Medication Error Reporting System (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/bundy-report.pdf
    January 01, 2024 - • A/D errors were more likely to originate with pharmacy staff and involve wrong dosage forms. … • Wrong-patient errors were also uncommon and often involved sibling-sibling confusion. … Wrong dosage form was the second most common error type in our study. … Similar-appearing packaging is another root cause of wrong vaccine errors. … In our study, wrong-time errors represented a commonly reported error type.

12. Event Investigation and Analysis Guide: Appendix A | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apa.html
    August 01, 2022 - Event Summary:   The wrong concentration of potassium (K+) was used in the compounding of TPN. … In this case, the drug was entered as the wrong concentration.

13. Premortem Assessment | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/mrsa-prevention/surgery/premortem-assessment.html
    April 01, 2025 - Usually when this happens, a postmortem project analysis is conducted to review what went wrong. … What could have gone wrong?

14. Why Is Improving Diagnosis Important? Physician and Patient Perspectives (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/schiff-summit2016.pdf
    January 01, 2013 - strategies at each stage of clinical practice Lucian Leape DEER Taxonomy Localizing What Went Wrong … Frequency in 583 cases DEER Taxonomy (continued) Localizing What Went Wrong Frequency in … 583 cases Schiff Arch Intern Med 2009 What went wrong: DEER Taxonomy Localization 8 Art Elstein … Clinical situations where patterns of, or vulnerabilities to errors leading to missed, delayed or wrong … injury, but chronic subdural hematoma later develops GENERIC TYPES of PITFALLS IOM (NAM) Estimate Wrong

15. Using Probabilistic Risk Assessment to Model Medication System Failures in Long-term Care Facilities (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Comden.pdf
    January 01, 2003 - , wrong-dose, omitted-dose or -drug, and wrong-patient medication administration errors in nursing and … Four classes of patient events (wrong- drug, wrong-dose, omitted-dose/drug, and wrong-patient medication … An ST– PRA risk tree starts with a top-level event, which is the undesirable outcome (e.g., a wrong … Example of risk or fault tree—dose transcribing error Gate80 Resident receives wrong dose due to … telephone/verbal order error Q:6.64335e-005 Event50 Facility hears correct dose and writes wrong

16. Final Progress Report: Oral Chemotherapy Safety in Ambulatory Oncology: A Proactive Risk Assessment (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/weingart-report.pdf
    January 01, 2024 - The most common medication errors involved wrong dose (38.8%), wrong drug (13.6%), wrong number of days … The majority of errors resulted in a near miss; however, 39.3% of reports involving the wrong number … or extra dose 117 (59.4) 26 (13.2 54 (27.4) 0 (0.0) Wrong drug 14 (20.3) 2 (2.9) 53 (76.8) 0 (0.0) Wrong … instructions 13 (76.5) 2 (100.0 ) 2 (11.8) 0 (0.0) Wrong frequency 12 (92.3) 0 (0.0) 1 (7.7) 0 (0.0 … P X X X 3 Errors when transmitting Rx to pharmacy P X X X 3 Wrong tabs, wrong liquid, wrong dose,

17. Improving Communication and Teamwork in the Surgical Environment Module | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/improving-slides.html
    October 01, 2020 - sites Wrong procedures Incorrect implants Missing equipment Mislabeling of specimens Delays … Operating room briefings and wrong-site surgery. … Reduced wrong-site surgeries and other adverse events. Increased staff morale. … site Wrong procedure Wrong/missing implant Wrong medications Unidentified allergy Wrong equipment … Operating room briefings and wrong-site surgery.

18. Voluntary Adverse Event Reporting in Rural Hospitals (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Schade_63.pdf
    January 01, 2007 - For example, the rate of reported wrong drug administration increased significantly among CAHs and … Drug Lab specimen-related Observed Falls Wrong Dose Staff Injury/exposure Elopement 6 Table 3. … medication administered Medication error Wrong drug name 15 1.71 2.20 0 – 2.67 2.48 Wrong dose of … wrong patient Surgery invasive procedure Wrong patient Treatment Wrong patient Medication … Reported rates of wrong drug administration increased significantly in CAHs but declined by about

19. Final Progress Report: Technology To Improve Medication Safety in Nursing Homes (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/scott-cawiezell-report.pdf
    January 01, 2024 - Scope Earlier research suggests that medication errors, excluding wrong-time errors, average 10% or … dose, wrong route) by the opportunities for error (OE). … wrong-time error reflects many specific system and timing issues that are often out of the control … Although the ICC was lower when considering medication errors without wrong-time medication errors ( … dose, wrong route, wrong preparation technique, wrong time, wrong monitoring technique, and omitted

20. Improving Communication and Teamwork in the Surgical Environment
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/improving/improving.pptx
    May 01, 2017 - sites Wrong procedures Incorrect implants Missing equipment Mislabeling of specimens Delays in surgery … Operating room briefings and wrong-site surgery. … Operating room briefings and wrong-site surgery. … site Wrong procedure Wrong/missing implant Wrong medications Unidentified allergy Wrong equipment … Operating room briefings and wrong-site surgery.