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Showing results for "wrong".

41. Improving Communication and Teamwork in the Surgical Environment Module: Facilitator Notes | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/improving-fac-notes.html
    May 01, 2017 - Operating room briefings and wrong-site surgery. … Use of the briefing card led to a drop in wrong-site surgeries and other adverse events. … Reported problems include wrong-site surgeries, wrong procedures, wrong or missing implants, wrong medications … , unidentified allergies, and/or wrong equipment. … Operating room briefings and wrong-site surgery.

42. TeamSTEPPS Learning Benchmarks (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/tools/ts-learning-benchmarks.pdf
    June 02, 2025 - The leader telling everyone what they did wrong. b. Meeting as a team to debrief the events. c. … The technologist is setting up for a procedure and notices that the doctor seems to be on the wrong … A wrong-headed approach to teamwork. 15. … 5 E • Ditto above • Tries to emphasize that the nurse didn’t have to know for sure that it was wrong

43. 130-Ss-Swiss-Cheese-Fg (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/130-ss-swiss-cheese-fg.docx
    April 01, 2025 - When things go wrong—which they will—it is important to learn from the issues or defects that contributed … to what went wrong. … For example, an anesthesiologist administers the wrong antibiotic or gives the wrong dose of an antibiotic

44. QSRS AI/ML Clinical Data Abstraction: Final Presentation (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/quality-measures/qsrs/qsrs-aiml-presentation.pdf
    January 05, 2005 - highest-scoring pages are always used High Confidence The LLM had access to the ● Prompt Engineering Wrong … Answer answer but didn’t find it ● Accuracy Improvement Work The wrong page was given ● Set thresholds … to flag human Low Confidence to the LLM - it never had a check Wrong Answer chance to get it right ●

45. Improving Patient Safety in Long-Term Care Facilities, Module 1 (pdf file)
    www.ahrq.gov/sites/default/files/publications/files/ltcmodule1.pdf
    June 01, 2012 - When one thing goes wrong, it seems to lead to another thing going wrong, and that can continue until … 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

46. Improving-Facnotes (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/improving/improving-facnotes.docx
    May 01, 2017 - communication has resulted in serious patient safety events such as teams performing a procedure on the wrong … Use of the briefing card led to a drop in wrong-site surgeries and other adverse events. … Reported problems include wrong-site surgeries, wrong procedures, wrong or missing implants, wrong medications … , unidentified allergies, and/or wrong equipment. … These include fears of being embarrassed, feeling stupid, being ridiculed, being yelled at, being wrong

47. PowerPoint Presentation: Premortem for Sustainability
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_premortem.pptx
    December 01, 2017 - efforts, the surgical safety program has failed—catastrophically Many things have gone completely wrong … ASK: What might have gone wrong? SAY: Let’s assume patient care hasn’t improved. … Ask each team member what she or he thinks could go wrong. ASK: Was staff overburdened?

48. AHRQ Safety Program for MRSA Prevention
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/154-performing-pre-mortem-project-assessment.pptx
    October 01, 2024 - What could have gone wrong? … Where process-improvement projects go wrong.

49. Mini Presentation: Performing a Premortem Project Assessment
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/108-performing-premortem-project-assessment.pptx
    April 01, 2025 - What could have gone wrong? … Where Process-improvement Projects Go Wrong.

50. On the CUSP: Stop BSI (ppt file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/contentcalls/assertion-slides/Assertion-Dec-14-2010-508.ppt
    January 01, 2010 - safety; it’s hard to disagree with safe, high-quality care Avoid the issue of who’s right and who’s wrong … “Patient-centered care”– It is not who is right or who is wrong, it is what is best for the patient

51. Optimize Briefings and Debriefings: Facilitator Notes | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/surgery/modules/implementation/opt-briefings-fac-notes.html
    December 01, 2017 - Where could things go wrong with this procedure and specifically with this case? … Slide 23: What Is Most Likely To Go Wrong? Ask: 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? … What went wrong, if anything? Were patient identification and specimen name verified?

52. Calibrate Dx: A Resource To Improve Diagnostic Decisions | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/tools/calibrate-dx.html
    March 01, 2023 - Calibrate Dx: A Resource To Improve Diagnostic Decisions Delayed, wrong, and missed

53. Final Progress Report: Show Your Work: Do Prescription Annotations Impact Near-miss Medication Errors? (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/johnson-baughman-report.pdf
    January 01, 2024 - Those errors include cognitive errors (wrong medication, no medication for an appropriate indication … , wrong patient); prescribing errors (wrong formulation, wrong dose, wrong route, wrong frequency, errors … Medication: Not Covered 20 3.97% Prior Authorization Needed 48 9.52% Therapeutic Duplication 14 2.77% Wrong … to Rx 15 2.98% Directions 55 10.91% Dosing 14 2.77% Drug-Drug Interaction 1 0.20% Duration 5 0.99% Wrong

54. Improving Error Reporting in Ambulatory Pediatrics with a Team Approach (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Neuspiel_43.pdf
    March 05, 2008 - The most frequent office administration error reports included wrong demographic information or date … medication and other treatment included miswritten vaccine and medication order near misses (five reports), wrong … vaccine administered (four reports), wrong outside prescription dispensed (three reports), incomplete … Medications Error: Wrong vaccine administered (several similar reports). … None of the AEs (e.g., wrong vaccine administered) resulted in significant harm to patients.

55. A System to Describe and Reduce Medical Errors in Primary 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-Kaprielian_9.pdf
    January 01, 2007 - Please check one or more of the following categories to identify the primary thing you believe went wrong … results 6. other “ Diagnosis 1. insufficient evaluation for diagnosis 2. wrong … missed diagnosis based on available data 3. other “ Medication 1. ordered incorrectly (wrong … medication, wrong dose, or not indicated) 2. no medication ordered when indicated 3. … follow-up (excluding diagnostic studies and medications) 1. ordered incorrectly (wrong

56. Facilitator Guide: Optimize Your Briefings and Debriefings (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_opt_briefings_facnotes.docx
    December 01, 2017 - Where could things go wrong with this procedure and specifically with this case? … Slide 22 What Is Most Likely To Go Wrong? ASK: What is most likely to go wrong? … Slide 23 What Is Most Likely To Go Wrong? … Slide 24 What Is Most Likely To Go Wrong? … What went wrong, if anything? Were patient identification and specimen name verified?

57. Learning from Errors in Ambulatory Pediatrics (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Mohr.pdf
    February 01, 2004 - They commonly mentioned medication errors, including prescribing and administering the wrong dosages … medication despite a known allergy; giving inaccurate telephone advice about dosage; and using the wrong … dosage or wrong technique to give immunizations. … (Problem type: Mechanical/Technical Malfunction) Administrative “The wrong appointment date was put … I don’t know how this wrong date got in the computer.”

58. Appropriate Assertion (Slide Presentation) | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/cusp/toolkit/content-calls/assertion-slides/assertion-slides.html
    October 01, 2014 - safety; it’s hard to disagree with safe, high-quality care Avoid the issue of who’s right and who’s wrong … “Patient-centered care”– It is not who is right or who is wrong, it is what is best for the patient

59. Sustainability and the Premortem Tool: Facilitator Notes | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/surgery/modules/sustainability/premortem-fac-notes.html
    December 01, 2017 - Ask: What might have gone wrong? Say: Let’s assume patient care hasn’t improved. … Ask each team member what she or he thinks could go wrong. Ask: Was staff overburdened?

60. Presentation: Optimize Your Briefings and Debriefings
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_opt_briefings.pptx
    December 01, 2017 - Where could things go wrong with this procedure and specifically with this case? … If something goes wrong, what should we look for and what are we going to do if that happens? … What went wrong? … What went wrong, if anything? Were patient identification and specimen name verified? … Wrong consents Wrong patients Incorrect equipment, implants, or instruments Comorbidities that have a