-
www.ahrq.gov/sites/default/files/2024-01/gurwitz-report.pdf
January 01, 2024 - Error types were further categorized as wrong dose, wrong
drug, missed dose, wrong frequency, extra … dose, wrong resident, known drug interaction,
inadequate laboratory monitoring, or delayed response
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www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/job-aid-presenting-data.pdf
June 02, 2025 - Stages of Data Grief
Denial These data are all wrong and we can't do anything.
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www.ahrq.gov/professionals/systems/system/delivery-system-initiative/casalino/paper/idkeydsr1.html
February 01, 2014 - system research at the present time, working from the premise that it is better to be specific and to be wrong
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/gdmod1a.html
October 01, 2014 - Not reporting a change can lead to other things going wrong.
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/diagnostic-safety-pilot-study-report.pdf
April 01, 2021 - reporting system that has a specific coded category to
document diagnostic errors such as missed, wrong … ; communications with providers who may have missed a diagnosis; and being
informed when a missed, wrong
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/booklets/laparotomy-patient.pdf
November 01, 2023 - in which a large opening is made in
the abdominal wall (the belly area) to take a look at what is wrong … Then, the surgeon takes a look to see what’s
wrong and repair it. … ■ If you feel sick to your stomach or you are throwing up
Call as soon as you think something is wrong
-
www.ahrq.gov/hai/cauti-tools/archived-webinars/engaging-nurse-physician-patient-slides.html
August 01, 2018 - a culture of safety
Easy to use:
Efficient
Continuity
Non-punitive:
“What” went wrong … , not “Who” went wrong
Ownership:
Engages frontline staff
Collaborative, multidisciplinary
-
www.ahrq.gov/hai/cusp/modules/apply/sl-cusp.html
December 01, 2012 - Understanding Risk and Human Behavior 1
Human Error:
Inadvertently completing the wrong action
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/surgery/6-gap-analysis-goal.docx
June 01, 2023 - There are no “right” or “wrong” answers.
-
www.ahrq.gov/hai/cusp/modules/apply/alt-text.html
March 01, 2013 - Understanding Risk and Human Behavior 1
Human Error:
Inadvertently completing the wrong
-
www.ahrq.gov/teamstepps-program/curriculum/implement/activity/plan.html
February 01, 2024 - Study the process to identify weak points where things could go wrong and lead to a recurrence of the … Identify risk points where things could go wrong and lead to a recurrence of the problem or challenge
-
www.ahrq.gov/sites/default/files/2024-02/cohen2-report.pdf
January 01, 2024 - an inability to swallow the prescribed capsules, incorrect verbal directions
from the physician, a wrong … application, each for use with a specific type of medication error,
including prescribing errors, wrong … patient and wrong drug data entry errors, prescription filling errors, and
dispensing errors at the … Prior studies show that more than 5% of medications first selected to
fill prescriptions are wrong,37 … and at least 75% of these wrong drug or wrong dose errors are captured and
corrected using barcode
-
www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/safer-guides-slides.pdf
February 18, 2025 - errors
• Unsafe workarounds for entering orders, notes, or
referrals
• Data entry or review of the wrong
-
www.ahrq.gov/patient-safety/settings/hospital/candor/demo-program/grants/summary.html
August 01, 2022 - The tool, "When Things Go Wrong in the Ambulatory Setting," contains "tips and suggested language for … apology, and offer needed emotional support" ( http://www.macrmi.info/blog/valuable-tool-when-things-go-wrong-ambulatory-setting-guideline-communication-and-resolution-outpatient-practices
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/medical-office/resources/infotransMOSOPS.pdf
January 01, 2010 - 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.
-
www.ahrq.gov/sops/international/medical-office/translators.html
January 01, 2010 - 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.
-
www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/dzau-summit2016.pdf
September 28, 2016 - errors can be defined as the failure of a planned
action to be completed as intended or the use of a wrong … medical malpractice claims
• Diagnostic errors can be costly - unnecessary office
and hospital visits, wrong
-
www.ahrq.gov/hai/tools/mvp/modules/sustainability/premortem-scorecard-slides.html
February 01, 2017 - Many things have gone completely wrong.
-
www.ahrq.gov/es/patient-safety/settings/hospital/vtguide/guide2.html
February 01, 2016 - those steps that occur less than 100 percent of the time, the team will want to identify things that go wrong
-
www.ahrq.gov/patient-safety/settings/hospital/vtguide/guide2.html
February 01, 2016 - those steps that occur less than 100 percent of the time, the team will want to identify things that go wrong