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Total Results: 360 records

Showing results for "wrong".

1. 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

2. 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

3. 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

4. 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?

5. 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

6. 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.

7. 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

8. 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.

9. 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.

10. AHRQ Safety Program for Ambulatory Surgery Final Report (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/ambulatory-surgery-report.pdf
    May 01, 2017 - site, wrong side, wrong patient, wrong procedure, wrong implant • Hospital transfer/admission from … Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant 287 0.72 (0.22–2.41) 0.60 Hospital … Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant 0.00% 0.01% 0.01% 0.01% 0.01% 0.00% … Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant 0.01% 0.00% 0.01% 0.01% 0.01% 0.00% … Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant 0.02% 0.01% 0.00% 0.00% 0.00% 0.00%

11. Defining Diagnostic Error: A Scoping Review to Assess the Impact of the National Academies’ Report Improving Diagnosis in Health Care (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/topics/defining-diagnostic-error-a-scoping-review.pdf
    April 27, 2022 - using the Australian Patient Safety Foundation classification of error as “unintendedly delayed, wrong … However, both stud- ies operationalized error using a combination of pre-NASEM definitions—wrong and … Gupta et al22 United States Failure to diagnose, delay in diagnoses, wrong diagnosis, and other … Evidence of omission (failure to do the right thing) or commission (doing something wrong) exists at … Given that the components of accuracy (e.g., missed, wrong, misdiagnosis) and timeliness (e.g., delayed

12. Optimize Briefings and Debriefings: Slide Presentation | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/surgery/modules/implementation/opt-briefings-slides.html
    December 01, 2017 - Slide 23: What Is Most Likely To Go Wrong? … Slide 24: What Is Most Likely To Go Wrong? … Slide 25: What Is Most Likely To Go Wrong? Other concerns Special precautions. … What went wrong? … Wrong consents. Wrong patients. Incorrect equipment, implants, or instruments.

13. Improving Communication and Teamwork in the Surgical Environment Module: Facilitator Notes | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/improving-fac-notes.html
    May 01, 2017 - Operating room briefings and wrong-site surgery. … Use of the briefing card led to a drop in wrong-site surgeries and other adverse events. … Reported problems include wrong-site surgeries, wrong procedures, wrong or missing implants, wrong medications … , unidentified allergies, and/or wrong equipment. … Operating room briefings and wrong-site surgery.

14. Summary of Survey Findings | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-culture-survey-brazil-summary.html
    August 01, 2024 - may have missed a diagnosis, and the second related to whether the office was informed when a missed, wrong … When a missed, wrong, or delayed diagnosis happens in this office, we are informed about it.  52.3% 56%

15. Improving-Facnotes (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/improving/improving-facnotes.docx
    May 01, 2017 - communication has resulted in serious patient safety events such as teams performing a procedure on the wrong … Use of the briefing card led to a drop in wrong-site surgeries and other adverse events. … Reported problems include wrong-site surgeries, wrong procedures, wrong or missing implants, wrong medications … , unidentified allergies, and/or wrong equipment. … These include fears of being embarrassed, feeling stupid, being ridiculed, being yelled at, being wrong

16. Introduction | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/probabilistic-thinking1.html
    September 01, 2022 - References Errors that occur during the diagnostic process can lead to missed or wrong

17. Optimize Briefings and Debriefings: Facilitator Notes | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/surgery/modules/implementation/opt-briefings-fac-notes.html
    December 01, 2017 - Where could things go wrong with this procedure and specifically with this case? … Slide 23: What Is Most Likely To Go Wrong? Ask: What is most likely to go wrong? … Slide 24: What Is Most Likely To Go Wrong? … Slide 25: What Is Most Likely To Go Wrong? … What went wrong, if anything? Were patient identification and specimen name verified?

18. TeamSTEPPS Video: Feedback (Long-Term Care) | Agency for Healthcare Research and Quality
    www.ahrq.gov/teamstepps-program/resources/additional/feedback.html
    July 01, 2023 - seconds) Feedback helps teams improve by providing timely, specific information on what went right or wrong

19. Measures of Cognitive Load | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-cognitive-load4.html
    May 01, 2024 - documentation, and choice of orders. 65 A validated submeasure that uses EHR audit log data is called the “Wrong-Patient … Retract-And-Reorder” (Wrong-Patient RAR) tool. … Similarly, improvement efforts that decrease the RAR rate should also decrease the number of wrong-patient

20. Calibrate Dx: A Resource To Improve Diagnostic Decisions | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/tools/calibrate-dx.html
    March 01, 2023 - Calibrate Dx: A Resource To Improve Diagnostic Decisions Delayed, wrong, and missed