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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-test-result-communication5.html
July 01, 2024 - recent investigations 114 have brought to light patient-reported concerns (e.g., access problems, wrong
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www.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-slides.html
December 01, 2017 - Are there aspects of your patient safety culture that promote doing the wrong thing or engaging in a … Attending notes that a transfusion has started, and that the unit of blood has the wrong patient’s name … However, the wrong chart was sent with the patient from the ICU.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/educational-bundles/urine-culturing/antibiotic-stewardship/abx-stewardship-part1.pptx
March 01, 2017 - type of knee-jerk or reflexive reaction can drive the resident workup and course of treatment in the wrong … Nausea, diarrhea
Allergic reactions
Antibiotic-related infections
Clostridium difficile
Candida (yeast)
Wrong … urine culture is also bad way to determine infection and subsequent treatment because you may make the wrong
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects.pptx
December 01, 2017 - Are there aspects of your patient safety culture that promote doing the wrong thing or engaging in a … Are there aspects of the patient safety culture that promote doing the wrong things? … The attending anesthesiologist then read the wrong patient’s name on the blood transfusion bag. … It was later determined that the wrong stamp had left the ICU with the patient at 5:30 a.m. … Frankly, wrong-site surgeries are too important a defect to merely hope for success.
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www.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-fac-notes.html
December 01, 2017 - Are there aspects of the patient safety culture that promote doing the wrong things? … The attending anesthesiologist then read the wrong patient’s name on the blood transfusion bag. … Slide 27: Case Study: Renal Transplant
Say:
The attending anesthesiologist asked about the wrong … It was later determined that the wrong stamp had left the ICU with the patient at 5:30 a.m. … Frankly, wrong-site surgeries are too important a defect to merely hope for success.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects_facnotes.docx
December 01, 2017 - Are there aspects of the patient safety culture that promote doing the wrong things? … The attending anesthesiologist then read the wrong patient’s name on the blood transfusion bag. … It was later determined that the wrong stamp had left the ICU with the patient at 5:30 a.m. … SAY:
However, interventions to reduce wrong-site surgeries may take years of collecting data before it … Frankly, wrong-site surgeries are too important a defect to merely hope for success.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Nosek.pdf
March 01, 2004 - 33.3% 31.3%
Type not determined 10.8% 0.1% 9.2% 0.02%
Unauthorized drug 8.6% 10.7% 7.3% 12.6%
Wrong … administration technique 1.8% 1.3% 0.6% 1.2%
Wrong dosage form 2.8% 1.5% 8.1% 7.1%
Wrong drug preparation … 6.1% 3.7% 9.7% 8.1%
Wrong patient 4.6% 4.2% 8.1% 9.2%
Wrong route 1.2% 1.6% 0.5% 0.8%
Wrong time
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www.ahrq.gov/sites/default/files/2024-09/kellogg-report.pdf
January 01, 2024 - Safety hazards that may be a result of increased workload include ordering the wrong
medication, ordering … the wrong lab or imaging study, or selecting the wrong patient from the electronic
health record.
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www.ahrq.gov/hai/cauti-tools/archived-webinars/assess-adapt-slides.html
July 01, 2018 - Three Principles of Safe Design
Standardize
Create independent checks
Learn when things go wrong … Slide 24
Learn When Things Go Wrong
First vs.
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www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/job-aid-practice-assessments.pdf
June 02, 2025 - Establish ground rules for discussion:
o There are no right or wrong answers.
-
www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-dx-stewardship8.html
August 01, 2024 - an analysis of recurring diagnostic “pitfalls,” Schiff and colleagues identified multiple cases of wrong
-
www.ahrq.gov/hai/tools/surgery/tools/surgical-complication-prevention/surgical-skinprep-audit.html
September 01, 2024 - We recommend that you collect data from 10 patients undergoing surgery, but there is no right or wrong
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/implementation-guide/appendix-k-study-elements.docx
June 02, 2025 - thorough analysis and team discussion can result in the pursuit of a solution that is headed in the wrong
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www.ahrq.gov/hai/tools/mrsa-prevention/toolkit/cusp.html
October 01, 2024 - By imagining scenarios where things go wrong, teams can spot vulnerabilities and plan to mitigate them
-
www.ahrq.gov/talkingquality/resources/design/testing.html
September 01, 2019 - how they happened to choose those particular ones; sometimes people get the "right" answer for the wrong
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www.ahrq.gov/sites/default/files/2024-01/field2-report.pdf
January 01, 2024 - For example, we needed frequencies for
events such as “lab results are faxed to the wrong office,” “ … Asks Wrong Question (probability reduced by 25%)
• Probability decreases from .3643 to .3369 (a reduction … CPOE Offers Wrong Frequency (probability reduced to 0%)
b. … Discharge Summary Wrong (probability reduced to 0%)
h.
-
www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/implementation-guide/study.html
May 01, 2017 - thorough analysis and team discussion can result in the pursuit of a solution that is headed in the wrong
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/169-cusp-science-safety-slides.pptx
October 01, 2024 - Learn, don’t just recover, when things go wrong. … | 23
AHRQ Safety Program for MRSA Prevention | ICU & Non-ICU
The Science of Safety
23
What’s Wrong
-
www.ahrq.gov/hai/tools/mrsa-prevention/surgery/cusp-mrsa-prevention.html
April 01, 2025 - By imagining scenarios where things go wrong, teams can spot vulnerabilities and plan to mitigate them
-
www.ahrq.gov/sites/default/files/2024-09/rogers-report.pdf
January 01, 2024 - The
most common errors were dosing errors (28%) followed by the wrong choice of drug
and errors of … ANA Sample
(n=199)1
AACN Sample
(n=224)2
Medication Errors 114 (57.3%) 127 (56.7%)
Wrong … patient 9 6
Wrong drug 20 13
Wrong dose 27 26
Wrong route 3 5
Wrong time 38 48
Omission