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Total Results: 725 records

Showing results for "wrong".

101. Four Moments of Antibiotic Decision Making | Agency for Healthcare Research and Quality
     www.ahrq.gov/antibiotic-use/long-term-care/four-moments/index.html
     August 01, 2021 - care staff recognize that something is not quite right with the resident but aren’t clear on what is wrong

102. Module 2: Urinary Catheter Maintenance | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/cauti-icu/facil-guide/mod2.html
     February 01, 2023 - Transporter: “Did I do something wrong?” Nurse:  “Not exactly. … In this scenario, the transporter didn’t understand what might happen because of wrong bag placement

103. Final Progress Report: NPSF Joint Medical-Legal Conference at SMU (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/nance-report.pdf
     January 01, 2025 - Physicians and nurses have a near-universal perception, right or wrong, that disclosure makes them a … physicians in particular do not disclosure simply because they do not believe that they did anything wrong … In addition, most physicians do not believe that silence (not disclosing) is wrong. … In brief, following knee replacement surgery, a nurse put the right pain medication in the wrong path … Therefore, finding fault in the personal and singular sense of pinpointing who was wrong in an accident

104. Issue Brief 26: Exploration of Foundational Terminology and Paradigms for Improving Diagnosis (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/resources/issue-briefs/dxsafety-terminology.pdf
     April 01, 2025 - recognition of error (the failure of a planned action to be completed as intended or the use of a wrong … 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

105. Final Progress Report: Automated Image Analysis for the Prevention of Radiotherapy Delivery Errors (pdf file)
     www.ahrq.gov/sites/default/files/2024-11/lamb-report.pdf
     January 01, 2024 - image guided radiotherapy, which would allow detection and prevention of delivery of radiation to the wrong … error leads to so-called never events: treatments with serious alignment errors 2 or with the wrong … interlock the radiotherapy machine to prevent treatment if the patient is not correctly aligned or if the wrong … Results have been obtained from 2018-2020 and indicate 2 unreported near-miss wrong-patient treatments

106. Transcript: How To Create Team Buy-In and Motivation To Get to Zero Infections (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/team-buy-in-transcript.pdf
     April 01, 2022 - We do root cause analysis when things go wrong. … And then from that, can we learn then what the gaps are between our practice where things did go wrong … Here's the practice that we should be following," the reaction of, "are you telling me I'm doing it wrong

107. Breaking Down Barriers to Aseptic Catheter Insertion (May 12, 2015) | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/archived-webinars/breaking-down-barriers-transcript.html
     December 01, 2017 - I got tongue tied at the wrong point in the conversation, so thanks so much for that. … But maybe I'm wrong about that. … If I'm not wrong, we can think of a way, perhaps, to deal with some of the barriers that we saw, and … Something can go wrong at any point. … I keep pushing the wrong button to advance the slide, sorry.

108. Breaking-Down-Barriers-Transcript (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/breaking-down-barriers-transcript.docx
     May 12, 2015 - I got tongue tied at the wrong point in the conversation, so thanks so much for that. … Maybe I'm wrong, but my guess is that our hospital and our experience is not unique. … But maybe I'm wrong about that. … Something can go wrong at any point. … I keep pushing the wrong button to advance the slide, sorry.

109. Taxonomic Guidance for Remedial Actions (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Thomadsen.pdf
     December 23, 2004 - At each new step, we not only focus on where the process went wrong, but also try to identify the underlying … • An action was called for but the wrong action was taken. … A mistake is a planning failure that happens when an incorrect intention is formed and the wrong action … failure a control panel with a poorly organized layout might increase the chance of hitting a wrong … button, but does not mean a wrong button will certainly be hit.

110. Presentation: Engaging Senior Executives
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_sr-execs.pptx
     December 01, 2017 - 0.14749999999999999 1.72E-2 Time Period SSI Rate (%) Technical and Adaptive Efforts Required2 Sentinel Event Alert: Wrong-Site … Surgery Aug 98 Sentinel Event Alert: Followup Review of Wrong-Site Surgery Dec 01 Wrong-site Surgery … Summit I Jan 03 Universal Protocol 2004 Wrong-site Surgery Summit II Feb 07 Revised Wrong-Site Surgery … AHRQ Safety Program for Surgery – Onboarding SAY: Despite numerous technical approaches to improve wrong-site

111. Tip 4. Use Writing Devices To Engage Readers of a Quality Report | Agency for Healthcare Research and Quality
     www.ahrq.gov/talkingquality/resources/writing/tip4.html
     May 01, 2015 - believe a myth to be true might be embarrassed or otherwise react negatively to finding out they are wrong

112. The Impact of a Web-based Reporting System on the Collection of Medication Error Occurrence Data (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Rudman.pdf
     January 01, 2004 - Improper dose 13.4%(392) 30.3%(290) Omission 24.0%(702) 16.6%(159) Prescribing 2.1%(62) 14.8%(141) Wrong … administration technique 5.2%(153) 1.2%(11) Wrong dose form 0.0%(1) 2.0%(19) Wrong drug preparation … 1.9%(54) 3.4%(33) Wrong patient 6.6%(192) 5.2%(50) Wrong route 1.7%(49) 2.0%(19) Wrong time 9.0%

113. 170-Cusp-Science-Safety-Notes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/170-cusp-science-safety-notes.docx
     October 01, 2024 - Safe systems have a mechanism to learn from events when something goes wrong. … For example, an anesthesiologist gives a patient the wrong antibiotic or the wrong dose of an antibiotic … Slide 23 What’s Wrong With This Picture?

114. 124-Cusp-Science-Safety-Fg (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/124-cusp-science-safety-fg.docx
     April 01, 2025 - Safe systems have a mechanism to learn from events when something goes wrong. … For example, an anesthesiologist gives a patient the wrong antibiotic or the wrong dose of an antibiotic … Slide 24 What’s Wrong With This Picture?

115. Slide 1 (ppt file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/health-literacy-pfe-070913.ppt
     July 01, 2013 - Focus on key messages and repeat Patients should leave you knowing 3 things: What is wrong? … Steps to Improve YOUR Skills * EXAMPLE 1: One Key Message for a Patient with a Catheter What’s wrong … EXAMPLE 2: One Key Message for a Patient with a Catheter * What’s wrong?

116. NAA National Webinar August 2024 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/action-alliance-webinar-august-2024.pdf
     January 01, 2024 - Alignment with Surgery Rotations https://www.aorn.org/outpatient-surgery/article/the-big- three-wrong-site-specialties … orthopedics, neurosurgery, urology https://www.aorn.org/outpatient-surgery/article/the-big-three-wrong-site-specialties … https://www.aorn.org/outpatient-surgery/article/the-big-three-wrong-site-specialties © 2023-2024

117. Implementing the New CAHPS® Protocol for Obtaining Patient Comments About Their Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/nyp-webinar-grob-prelim-phase-one.pdf
     June 02, 2025 - the waiting room for one hour after my visit was over because the desk put my discharge file in the wrong

118. Shaping the Future of Patient Empowerment and Care Delivery Through Digital Healthcare Research | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/blog/ahrqviews/shaping-the-future-through-dhr.html
     September 01, 2024 - After confirming that using patient photos can significantly reduce wrong patient orders, the team is

119. 2022 Updated Results for the AHRQ Surveys on Patient Safety CultureTM (SOPS®) Diagnostic Safety Supplemental Items for Medical Offices (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/DxSftyRpt-Updated-2022.pdf
     January 01, 2022 - reporting system that has a specific coded category to document diagnostic errors such as missed, wrong … diagnosis; communicating with providers who may have missed a diagnosis; and being informed when a missed, wrong … (Item DXC3, NA/DK/MI = 49%) 55 When a missed, wrong, or delayed diagnosis happens in this office, … (Item DXC3) 51% 69% 55% 55% 62% 47% When a missed, wrong, or delayed diagnosis happens in this office … (Item DXC3) 58% 54% 58% When a missed, wrong, or delayed diagnosis happens in this office, we are informed

120. Understanding Quality and Safety Problems in the Ambulatory Environment: Seeking Improvement With Promising Teamwork Tools and Strategies (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Webster_76.pdf
     July 18, 2008 - Institutionalizing the process in one’s practice avoids some of the problems with wrong medication, … wrong dose, wrong person, and wrong route problems that may result in ADEs. … Operating room briefings and wrong-site surgery. J Am Coll Surg 2007; 204: 236-243. 59. IHI. … Universal protocol for preventing wrong site, wrong procedure, wrong person surgery.