Results

Total Results: 725 records

Showing results for "wrong".

121. Introduction to Diagnostic Errors | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-cognitive-load1.html
     May 01, 2024 - diagnostic errors were found in 23 percent of cases. 4 While the cause of these delayed, missed, or wrong

122. Technology for Improving Medication Monitoring in Nursing Homes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Lapane.pdf
     March 09, 2005 - that focus on the reduction of medication errors at the point of prescribing (e.g., prevention of the wrong … • Effectiveness (whether the patient is receiving the wrong drug or dosage form, whether contraindications … are present, whether the patient is receiving the wrong dose or frequency of administration, whether … • Safety (whether a wrong dose or duration of therapy is used, whether there is an adverse drug reaction … recommen- dation Recommend therapy Document in PCP Dose too high; Adverse drug reaction Wrong

123. The Incident Decision Tree: Guidelines for Action Following Patient Safety Incidents (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Meadows.pdf
     December 01, 2003 - Despite the dedication and professionalism of staff, things can and do go wrong. … Such cases often involve a “perceptual slip,” such as picking up the wrong medication or ticking the … wrong box on a form. … contributes significantly to the blame culture and creates a Russian roulette effect, where being in the wrong … place at the wrong time becomes the greatest predictor of punishment

124. Improving Patient Safety in Long-Term Care Facilities, Module 3 (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/ltcmodule3.pdf
     June 01, 2012 - they aren’t working right, learn how to fix problems, and learn how to recover when things do go wrong … An experienced care team has seen things go wrong in the care system. … We learn best when we talk about how things might or did go wrong. … Learning is much harder if we can’t see what happens when things go wrong for others or can’t get feedback … Usually, when things go wrong it is because a provider was too tired, distracted, didn’t know how things

125. Final Progress Report: How Do Consumers View the Risks of Medical Errors? (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/peters-report.pdf
     January 01, 2024 - Factor 1 relate to surgical errors, such as leaving an instrument in the patient; operating on the wrong … patient or wrong limb, or unnecessarily on the heart; or just general errors in surgery. … Low scores on Factor 2 relate to problems the patient could detect and correct, such as wrong diet or

126. Final Progress Report: Managing the Health Needs of Vulnerable Children (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/seid-sobo-report.pdf
     January 01, 2024 - thing to them and help them understand what’s going on with their child – they want to be told what’s wrong … “[Doctors] should talk to their patients about what’s wrong…explain things to them and what kind of … Because I, myself, have had the experience of being prescribed the wrong medication.”

127. CommonSpirit Health Expands CANDOR Toolkit Across Entire Health System | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/202104.html
     October 01, 2021 - and clinicians communicate accurately and openly with patients and their families when something goes wrong

128. SOPS Medical Office Items and Composite Measures (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/MO_Items-Composite_Measures.pdf
     June 02, 2025 - The wrong chart/medical record was used for a patient. Charts/Medical Records A3. … Medical information was filed, scanned, or entered into the wrong patient’s chart/medical record.

129. Changing-System-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-facilitator-guide.docx
     June 01, 2021 - An example of an active failure is a resident receiving the wrong medication because someone misread … Also, a health care practitioner may write the wrong dose of an antibiotic because he or she is unaware … Though the resident can still receive the wrong medication due to human error, or active failures, we

130. Final Progress Report: Medication Error Reduction, Technologies and Human Factors (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/carayon-report.pdf
     January 01, 2024 - These were analyzed using Microsoft Excel to identify medication errors (e.g., wrong dose, etc.) and … The most common error reported pre-implementation was wrong dose (17%), followed by wrong drug (8.4% … ), wrong rate (6.1%), and wrong concentration (3%). … Wrong dose (18%) and wrong drug (5.4%) were the most commonly reported errors post-implementation. … physically on the patient, not documenting a medication that was administered, and administering the wrong

131. SOPS® Diagnostic Safety Supplemental Items for the SOPS Medical Office Survey (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/diagnostic-safety-suppl-items.doc
     June 02, 2025 - When a missed, wrong, or delayed diagnosis happens in this office, we are informed about it (1 (2

132. Recognizing and Celebrating Success: Transcript - Sustainability Module | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/training-tools/success-transcript.html
     June 01, 2017 - seemed like the first successes were in the ophthalmology rooms, where we had saved opening up the wrong

133. Sustainability and the Premortem Tool: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/surgery/modules/sustainability/premortem-slides.html
     December 01, 2017 - Many things have gone completely wrong.

134. Tool: Two-Challenge Rule | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps-program/curriculum/mutual/tools/rule.html
     May 01, 2023 - Matt replies that Judy is wrong, as Mrs. Peters’ menu card says “regular diet.”

135. Tool: Advocacy and Assertion | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps-program/curriculum/mutual/tools/advocacy.html
     June 01, 2023 - this scenario, an assertive statement may be appropriate even though the physician has done nothing wrong

136. New AHRQ SOPS® Diagnostic Safety Supplemental Items for Medical Offices - Yount (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/04-new_sops_diagnostic_safety-yount.pdf
     October 20, 2021 - this office/ svstem may have missed a diagnosis, they inform that provider. 55 When a missed, wrong … (NA/DK/MI = 49%) 55 When a missed, wrong, or delayed diagnosis happens in this office, we, are

137. Health Literacy and Patient and Family Engagement: Strategic Tools to Prevent CAUTI | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/archived-webinars/health-literacy-slides.html
     December 01, 2017 - Skills Focus on key messages and repeat Patients should leave you knowing 3 things: What is wrong … Slide 26 Example 1: One Key Message for a Patient with a Catheter What’s wrong? … Slide 27 Example 2: One Key Message for a Patient with a Catheter What’s wrong?

138. CAUTI Prevention Implementation in a Community Hospital
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/assess-adapt-060314.pptx
     March 01, 2009 - Three Principles of Safe Design 18 Standardize Create independent checks Learn when things go wrong … 23 Learn When Things Go Wrong 24 First vs.

139. Final Progress Report: Enhanced Patient Safety Intervention to Optimize Medical (EPITOME) (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/sirio-report.pdf
     January 01, 2024 - patients met one or more of the following criteria: 1) admitted for drug-related problem (patient took wrong … medication or wrong dose; patient experienced an adverse drug-related event or drug interaction); … particular patient’s educational needs or 2) the patient was admitted for drug-related problem (e.g., wrong … medication, wrong dose, drug interaction, adverse drug reaction).

140. Recognizing-Success-Transcript (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/recognizing-success-transcript.docx
     May 01, 2017 - seemed like the first successes were in the ophthalmology rooms, where we had saved opening up the wrong