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Showing results for "wrong".

21. Final Progress Report: Developing a Medical Biometric Identification System with a Secure Database Network That Can Access Electronic Medical Databases (pdf file)
    www.ahrq.gov/sites/default/files/2024-07/sohn-report.pdf
    January 01, 2024 - wrong  surgical  procedure.”  … The  number  of  wrong  surgeries  still  increases  every  year, as  shown  in  Figure  2  [3].  … Root causes of wrong-site surgery in 2005, as reported by The Joint Commission Figure 2. …   Wrong  Procedure,   Wrong   Person   Surgery  has   been   required   of   all The   Joint   Commission … al.,  Automatic  Detection   and  Notification   of   "Wrong   Patient‐Wrong Location"  Errors  in  

22. 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%

23. Final Progress Report: Inpatient-Outpatient Transitions: Reducing the Rate of Readmissions (pdf file)
    www.ahrq.gov/sites/default/files/2025-02/jones-selna-report.pdf
    January 01, 2025 - level of care 9 7 6 378 Process Step 4: Daily Care Plan Update Wrong plan Discharged w/wrong … all team members present wrong/poor plan inadequate care 9 9 9 9 5 5 405 405 Process … Step 9/10: D/C Synopsis and D/C Instructions None inadequate care 9 8 4 288 wrong/poor plan 9 8 4 … No med rec wrong meds 10 8 9 720 inadequate care 10 8 9 720 complications 10 8 9 720 Process Step … 12:Med Rec Inaccurate med rec wrong meds 10 8 9 720 inadequate care 10 8 9 720 complications 10 8

24. 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

25. New AHRQ SOPS™ Health Information Technology Patient Safety Supplemental Items for Hospitals - (Yount) (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospital/healthitwebinar/sops-hit-webcast4-yount.pdf
    June 02, 2025 - Patient Safety and Quality Issues 35 In the past 3 months… “A lot of the medication lists are either wrong … "I do a lot of chart reviews…and I frequently find wrong information in [physician] progress notes.” … Patient Safety and Quality Issues 37 In the past 3 months… “Patient information is scanned in [the] wrong

26. A Visual Computer Interface Concept for Making Error Reporting Useful at the Point of Care (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Singh_69.pdf
    April 04, 2008 - In this case, the error is that the primary doctor (who is reporting this error) refilled the wrong … Lab Phone/Fax Chart Select Error: Wrong patient Wrong medication Wrong dose Wrong frequency Wrong … route Wrong # of doses Wrong #of refills StorySeverity Click on this error Click where the error … Consequences of Error: Wrong dose Select the Consequence from the list Click on this consequence G … Consequences of Error: Wrong dose Click on the Severity level Severity Level 1. ................ 2.

27. Final Progress Report: Proactive Risk Assessment in the ED: Building the Safety Case (pdf file)
    www.ahrq.gov/sites/default/files/2025-03/wears-perry-report.pdf
    January 01, 2025 - Wrong status. … Wrong disposition. … Patient data initially entered incorrectly - wrong name. … Patient data initially entered incorrectly - wrong location. … Wrong disposition.

28. Lessons Learned from the Evolution of Mandatory Adverse Event Reporting Systems (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Flink.pdf
    April 09, 2004 - surgery and infant abduction, correlate closely with two NYPORTS codes—911 (wrong- patient/wrong-site … An analysis of wrong- patient/wrong-site surgical errors led to the development of the New York preoperative … /wrong-site surgery, wrong procedures, and Lessons from Mandatory Reporting Systems 145 procedures … As a result of the adoption of the protocols and NYPORTS analysis, the number of wrong-patient/wrong-site … Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery.™ December 2003

29. Session 1 | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mod2sess1.html
    October 01, 2014 - Sometimes people worry about reporting a change because they feel that something has gone wrong, and … They have also seen things go wrong in the care system. … When things go wrong or look as if they nearly did, we tend to feel embarrassed and worry that if we … Not being able to talk about how things did or could go wrong holds back our own learning. … Usually, when things go wrong it is because a provider was too tired, distracted, didn't know the system

30. Serious Reportable Adverse Events in Health Care (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Kizer2.pdf
    December 01, 2000 - or wrong body part or transfusing the wrong type of blood into a patient—suggests (but does not prove … Surgery performed on the wrong body part Defined as any surgery performed on a body part that is … Surgery performed on the wrong patient Defined as any surgery on a patient that is not consistent … Infant discharged to the wrong person B. … drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration

31. Evaluation of Medications Removed from Automated Dispensing Machines Using the Override Function Leading to Multiple System Changes (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Miller_93.pdf
    March 12, 2008 - highest percentage of errors was attributable to manual replenishment functions, returning drugs to the wrong … nine of the transactions: three administrations had no documented physician order; one involved the wrong … route; in two instances, the wrong medication was given; and two patients received the wrong dose. … , wrong route, or wrong dose error. … Olanzapine IM was removed from the formulary to decrease the risk of the wrong medication being given

32. 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.

33. Session 1 | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mod3sess3.html
    October 01, 2014 - when 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

34. Appendix E | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/findings/final-reports/environmental-scan-programs/envscan-program-ape.html
    April 01, 2018 - 413 Fatigue and Sleep Deprivation 13 411 Identification Errors 18 443  -- Wrong … Patient 7 444  -- Wrong-Site Surgery 12 426 Medical Complications 26 429 … Complications 12 440  ---- Retained Surgical Instruments and Sponges 0 447  ---- Wrong-Site

35. 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

36. 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%

37. 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

38. Session 2 | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mod1sess2.html
    October 01, 2014 - them because changes for these residents can be sudden, and they may not be able to tell you what's wrong … They have also seen things go wrong in the care system. … When things go wrong or look as if they are about to (near-misses), we tend to feel embarrassed, and … Not being able to talk about how things did or could go wrong holds back our own learning. … Learning is much harder if we can't see what happens when things go wrong for others, or we can't get

39. Improving Patient Safety in Long-Term Care Facilities, Module 2 (pdf file)
    www.ahrq.gov/sites/default/files/publications/files/ltcmodule2.pdf
    June 01, 2012 - Sometimes people worry about reporting a change because they feel that something has gone wrong, and … They have also seen things go wrong in the care system. … When things go wrong or look as if they nearly did, we tend to feel embarrassed and worry that if we … Sometimes people worry about reporting a change because they feel that something has gone wrong, and … They have also seen things go wrong in the care system.

40. National Content Series Discussion Guide - The Culture of Culturing: The Importance of Knowing When To Order Urine Cultures | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/education-bundles/urine-culturing/when-to-order/worksheet.html
    May 01, 2017 - What went wrong during this interaction between Nurse Nohai and Dr. Killbug?     2.