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Total Results: 725 records

Showing results for "wrong".

401. News Media and Health Care Providers at the Crossroads of Medical Adverse Events (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Whitten_85.pdf
     June 05, 2008 - 27 types of major adverse events.11 These include surgical events (e.g., surgery performed on the wrong … the use of contaminated drugs or devices); patient protection events (e.g., infant discharged to the wrong

402. Using an Anonymous Web-Based Incident Reporting Tool to Embed the Principles of a High-Reliability Organization (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Conlon_50.pdf
     May 06, 2008 - a surgical procedure to speak up during the timeout to avoid mistakes that might occur related to wrong … patient or wrong site in the operating room suite.

403. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-cognitive-load-references.html
     May 01, 2024 - Understanding and preventing wrong-patient electronic orders: a randomized controlled trial.

404. Displaying the Data in a Health Care Quality Report | Agency for Healthcare Research and Quality
     www.ahrq.gov/talkingquality/translate/display/index.html
     May 01, 2019 - design is as follows: If people need a lot of explanation to understand your graphic, there's something wrong

405. Sensemaking and Learn From Defects for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-fac-guide.html
     July 01, 2023 - rule-based failure occurs when a person does not carry out a procedure or protocol correctly or chooses the wrong

406. Assess-Resident-Uti-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/assess-resident-UTI-facilitator-guide.docx
     June 01, 2021 - Does anything else feel off or wrong?

407. Antibiotic-Targets-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/antibiotic-targets-facilitator-guide.docx
     June 01, 2021 - Residents can get sick on the wrong therapy.”

408. Central Venous Catheter Maintenance Facilitator Notes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/central-catheter-maintenance-notes.docx
     April 01, 2022 - A wrong connector can lead to CLABSI.

409. Module 2: Communication and Optimal Resolution (CANDOR) Toolkit Module 2: Obtaining Organizational Buy-in and Support
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module2/module2-obtaining-organizational-buy-in-support.pptx
     August 14, 2015 - behaviors related to risk is described in three categories: Human error—Inadvertently completing the wrong

410. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/assess-psc-hsop-facguide.docx
     January 01, 2017 - In a way, this culture helps us understand what is good, bad, right, and wrong, so that we can also understand

411. Learn-From-Defects-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.docx
     May 01, 2017 - rule-based failure occurs when a person does not carry out a procedure or protocol correctly or chooses the wrong

412. Facilitator Guide: Science of Safety Training & Identifying Defects (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_scienceofsafety_facnotes.docx
     December 01, 2017 - condition, a patient fall, a venous thromboembolism, a medication error, a surgical site infection, wrong-site

413. Mod4-System-Focused-Event-Guide (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4/mod4-system-focused-event-guide.pdf
     April 01, 2016 - Wrong. The problem is seldom the fault of an individual; it is the fault of the system. … Event Summary: The wrong concentration of potassium (K+) was used in the compounding of TPN. … In this case, the drug was entered as the wrong concentration.

414. Final Progress Report: A Study of Narrative as the Cognitive Process Underlying Diagnostic Reasoning (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/smith2-report.pdf
     January 01, 2025 - pneumonia: cough, shortness of breath and fever and the classic physical findings, but it was the wrong

415. The History of Patient Roles | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patient-role2.html
     September 01, 2024 - Healers, physicians, and surgeons used their skills to fix what was deemed wrong with the patient’s body

416. Teaching Implementation Coaching for Culture Change | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps-program/curriculum/team/implement/teach-coach.html
     February 01, 2024 - Without accurate assessment, coaching efforts might be spent addressing the wrong problem or a nonexistent

417. Improving Patient Safety Systems for Patients With Limited English Proficiency: A Guide for Hospitals (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/lepguide.pdf
     September 01, 2012 - errors happen when something that was planned as part of medical care does not work out or when the wrong … Never event**: The term “never event” refers to a particularly shocking medical error (such as wrong-site … Immediately after I realized I had done the wrong exam I called the doctor and had him reorder the exam … • Wrong language interpreter being sent. … When things go wrong: responding to adverse events. A consensus statement of the Harvard hospitals.

418. Slide 1 (ppt file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/contentcalls/zero_clabsis-slides/Sustaining-Zero-CLABSIs-May-8-2012-508.ppt
     January 01, 2012 - Hospital leadership gives “good catch” pins to staff who identify and correct a patient safety near miss Wrong

419. Measure Dx: A Resource To Identify, Analyze, and Learn From Diagnostic Safety Events (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/MeasureDx-guide.pdf
     July 01, 2022 - the occurrence of one or both of the following (whether or not the patient was harmed): � Delayed, Wrong … Measure Dx | 48 Where in the Diagnostic Process What Went Wrong 1. Access/Presentation a. … Ordering of wrong test(s) e. … Tests ordered wrong way Performance (traditionally called “analytic phase”) f. … Sample mix-up/mislabeled (e.g., wrong patient/test) g. Specimen delivery problem h.

420. Measure Dx: A Resource To Identify, Analyze, and Learn From Diagnostic Safety Events (pdf file)
     www.ahrq.gov/sites/default/files/publications2/files/MeasureDx-guide.pdf
     July 01, 2022 - the occurrence of one or both of the following (whether or not the patient was harmed): � Delayed, Wrong … Measure Dx | 48 Where in the Diagnostic Process What Went Wrong 1. Access/Presentation a. … Ordering of wrong test(s) e. … Tests ordered wrong way Performance (traditionally called “analytic phase”) f. … Sample mix-up/mislabeled (e.g., wrong patient/test) g. Specimen delivery problem h.