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Total Results: 725 records

Showing results for "wrong".

341. Presentation: Program Overview
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/learn-from-defects-slides.pptx
     January 01, 2017 - Are there aspects of your patient safety culture that promote doing the wrong thing or engaging in a

342. Final Progress Report: Diagnostic Error in Medicine Annual Conference (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/singh2-report.pdf
     January 01, 2025 - intense pressure for action, attention has centered on “low-hanging fruit,” such as medication errors, wrong-site … which diagnosis is unintentionally delayed (though sufficient information was available earlier), wrong

343. Final Progress Report: Cook County & Rush Developmental Center for Research in Patient Safety: Diagnosis Error Evaluation and Research (DEER) Project (pdf file)
     www.ahrq.gov/sites/default/files/2025-04/schiff-mcnutt-report.pdf
     January 01, 2025 - It identifies what went wrong, situating where in the diagnostic process the failure occurred. … 4) How did the error in the diagnostic process contribute to making the wrong diagnosis and wrong treatment … Participants’ judgments of what was done wrong can be used not as a way to conclusively judge what happened

344. Special Considerations for Measurement of Diagnostic Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/state-of-science-2.html
     June 01, 2020 - a complex, adaptive sociotechnical system. 25,26 Safe diagnosis (as opposed to missed, delayed, or wrong

345. Final Progress Report: Shared Decision Making in Surgery To Improve Patient Safety and Reduce Liability (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/domino-report.pdf
     January 01, 2024 - Other errors occurring in 5% or more cases were medical or surgical management errors (9%), wrong treatment … to diagnose 9 (19%) Medication error 7 (15%) Laboratory error 5 (11%) Retained foreign body 4 (9%) Wrong … , equipment injuries (n=3), diagnosis errors (failure or delay, n=3), retained foreign body (n=2), wrong

346. Final Progress Report: Risk Analysis of Pediatric Chemotherapy Processes (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/shenep-report.pdf
     January 01, 2024 - Potential failures identified from FMEA: 3.1 Illegible order RPN score: 80 3.2 Orders generated on wrong … Potential failures identified from FMEA: 11.1 Report initialed in wrong spot on the report RPN score … Potential failures identified from FMEA: 1.1 Labels print on wrong date due to incorrect scheduling

347. Final Progress Report: Auditory Perception of Drug Names: Neighborhood Effects (pdf file)
     www.ahrq.gov/sites/default/files/2024-03/lambert3-report.pdf
     January 01, 2024 - Scope: Drug names that sound alike contribute to the roughly 4 million wrong-drug errors committed annually … ®).6-8 Observational studies of dispensing errors in community pharmacies suggest that the rate of wrong-drug … Assuming roughly 4 billion outpatient prescriptions annually in the US, this translates to 5.2 million wrong-drug … Substitution errors are more interesting, because they correspond to potentially harmful wrong-drug errors

348. Preventing CAUTI in the ICU Setting Facilitator’s Guide Transcript | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/facil-guide/preventing-cauti-icu-setting-transcript.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

349. Using Root Cause Analysis to Help Practices Understand and Improve Their Performance and Outcomes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-11-root-cause-analysis.pdf
     December 27, 2021 - Human causes involve someone doing something wrong, not doing something that should be done, or doing … Categories of Root Causes: Examples Human causes: Medical assistant is entering information in the wrong

350. Antibiotic Audit Tool | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/surgery/tools/surgical-complication-prevention/antibiotic-audit.html
     December 01, 2017 - We recommend that you collect data from 10 patients undergoing surgery, but there is no right or wrong

351. Coaching Clinical Teams Module | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/coaching-slides.html
     May 01, 2017 - Thinking Example of making the team guess what you are thinking "Can you tell me what you did wrong

352. Chapter 2. What is Care Coordination? | Agency for Healthcare Research and Quality
     www.ahrq.gov/ncepcr/care/coordination/atlas/chapter2.html
     June 01, 2014 - care professionals notice failures in coordination particularly when the patient is directed to the "wrong

353. Information to Help Hospitals Get Started (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/howtogetstarted/How_PFE_Benefits_Hosp_508.pdf
     January 01, 2012 - Hospitals are becoming increasingly frustrated - and wasting money - trying to hit the wrong target

354. Managing Interruptions to Improve Diagnostic Decision-Making: Strategies and Recommended Research Agenda (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/topics/managing-interruptions-improve-diagnostic-decisionmaking.pdf
     December 29, 2022 - used during this time-out, which asks individuals to imagine a future where the current diagnosis is wrong … ever, several studies have abandoned such interventions, fearing the do-not-disturb vests sent the wrong

355. Organizational Behavior Management in Health Care: Applications for Large-Scale Improvements in Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Cunningham_11.pdf
     January 29, 2008 - process of care itself or failure of a planned action to be completed as intended or the use of a wrong … they are process- rather than outcome-based and include: • Diagnosis errors, such as using the wrong … • Treatment errors, such as ordering a wrong drug or dosage, accidental puncture or laceration, and

356. Diagnostic Safety Issue Brief 21 Diagnostic Stewardship as a Model To Improve the Quality and Safety of Diagnosis (pdf file)
     www.ahrq.gov/sites/default/files/publications2/files/dx-safety-21-diagnostic-stewardship.pdf
     August 01, 2024 - testing.23-25 Diagnostic Error in the Testing Process Diagnostic errors include missed, delayed, and wrong … ordering urine cultures in patients without urinary tract symptoms, which can increase the risk of wrong … specimen mishandling; for instance, contamination of specimens at the time of collection can result in wrong … an analysis of recurring diagnostic “pitfalls,” Schiff and colleagues identified multiple cases of wrong

357. An Ambulatory Care Curriculum for Advancing Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Mottur.pdf
     June 01, 2005 - An analysis of what went wrong follows the case, which, according to Bloom, is the analysis level. … By recognizing what went wrong, physicians can avoid similar errors in the future.

358. Presentation: Program Overview
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/vae/vaesurveillance-slides.pptx
     January 01, 2017 - complications of MV, not just pneumonia When definitions are objective, caregivers can focus on what went wrong

359. AHRQ Safety Program For Long-Term Care: CAUTI
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module4/module-4-slides.pptx
     March 01, 2017 - Families Fear of – Being embarrassed Feeling stupid Being ridiculed Someone yelling at them Being wrong

360. Facapplycusp (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/apply/facapplycusp.docx
     June 02, 2025 - risk, and this continuum is described in three categories: · Human error—Inadvertently completing the wrong