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Total Results: 725 records

Showing results for "wrong".

61. Final Progress Report: Blood Product Transfusion & Safe Practices (pdf file)
    www.ahrq.gov/sites/default/files/2024-02/herwaldt-report.pdf
    January 01, 2024 - Surgery Clinic requires that staff print labels the day before the patient’s procedure, resulting in a ‘wrong … Wrong steps occurred when the user simply chose the incorrect transaction within the “Transfusion: Blood … The aborted scans were sorted into mis-scans, skipped steps, wrong steps, and prevented errors using … ug -0 5 S ep -0 5 O ct -0 5 N ov -0 5C ou nt o f A bo rt Sc an s in C at eg or y Wrong … completed correctly Mis-scan = Invalid PID scans don’t match on same step, or invalid barcode scanned Wrong

62. Measures of Cognitive Load | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-cognitive-load4.html
    May 01, 2024 - documentation, and choice of orders. 65 A validated submeasure that uses EHR audit log data is called the “Wrong-Patient … Retract-And-Reorder” (Wrong-Patient RAR) tool. … Similarly, improvement efforts that decrease the RAR rate should also decrease the number of wrong-patient

63. Final Progress Report: Evaluation of Risk by Active Surveillance in the Emergency Department (ERASED) (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/hall1-report.pdf
    January 01, 2024 - category (e.g., medication delivery; laboratory testing) and specific event type (e.g., administration – wrong … Performance – delay or failure to perform 13 Results – delay or failure to report results 5 Performance – wrong … study performed 3 (1) Ordering – delay or failure to order 1 Ordering – wrong study ordered 1 Results … delay or failure 2 Inadequate resident or fellow supervision 1 (1) Medications Dispensing – delay or wrong … dose 1 Ordering – wrong time 1 Dispensing – wrong route 1 Procedures IV access – unanticipated difficulty

64. Module 2: Urinary Catheter Maintenance Facilitator Notes | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/cauti-tools/facil-guide/preventing-cauti-icu-setting-module2-speaker-notes.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

65. Final Progress Report: TOP-MEDS CERT: Tools for Optimizing Medication Safety (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/lambert-report.pdf
    January 01, 2024 - Drug name confusion causes patients to receive the wrong drugs. … In the United States, roughly one per thousand prescriptions results in the wrong drug being filled … Despite advances in computerized prescriber order entry (CPOE), wrong-drug errors are still reported … and wrong-patient errors. … and wrong-patient errors and improve the completeness of the problem list.

66. Session 1 | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mod1sess1.html
    October 01, 2014 - When one thing goes wrong, it seems to lead to another thing going wrong, and that can continue until … Not reporting a change can lead to other things going wrong.

67. Premortem Tool | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/mvp/modules/cusp/premortem-tool.html
    January 01, 2017 - Things have gone completely wrong on a number of fronts. What could have caused this?" … Things have gone completely wrong on a number of fronts. What could have caused this?

68. Facilitator Guide: Sustainability and the Premortem (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_premortem_facnotes.docx
    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?

69. Appendix 1-B. Pre/Post-Test Questions and Answers for Module 1 | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/gdmodap1b.html
    October 01, 2014 - You ask the resident what is wrong, telling him you will check on his lunch, and then notify the licensed … You ask the resident what is wrong, telling him you will check on his lunch, and then notify the licensed

70. Tool 1. Staff Meeting Discussion Guide | Agency for Healthcare Research and Quality
    www.ahrq.gov/ncepcr/tools/obesity/obpcp-tool1.html
    May 01, 2014 - Address ground rules: There are no right or wrong answers.

71. TeamSTEPPS Video Debrief Guide: Debrief in Emergency Department (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/video/debrief-emergency-dept-guide.pdf
    June 02, 2025 - In discussing what went wrong, the team can make plans to implement solutions.

72. 045-Ss-Tips-Patient-Ed (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/045-ss-tips-patient-ed.docx
    April 01, 2025 - Check again—and if they get it wrong, go over it again.AHRQ Pub.

73. The Association Between Pharmacist Support and Voluntary Reporting of Medication Errors: An Analysis of MEDMARX® Data (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Jones_91.pdf
    July 17, 2008 - drug Wrong time Extra dose Wrong patient Wrong route Wrong administration technique Drug … prepared incorrectly Wrong dosage form Mislabeling Expired product Deteriorated product … 55.3 43.4 1.3 (N = 286) 66.1 32.9 1.0 (N = 21,102) 83.3 15.4 1.3 Unauthorized/wrong … N = 217) 26.3 73.3 0.5 (N = 711) 38.3 61.6 0.1 (N = 21,044) 44.1 54.0 1.9 Wrong … (N = 169) 26.6 72.8 0.6 (N = 356) 38.2 61.2 0.6 (N = 9,652) 32.7 65.5 1.8 Wrong

74. Contributions to Patient Safety and Medical Liability | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/demo-program/grants/contributions.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

75. Final Progress Report: Risks of Inaccurate or Incomplete Preoperative Assessments in Freestanding ASCs (pdf file)
    www.ahrq.gov/sites/default/files/2024-11/kupka-report.pdf
    January 01, 2024 - surgery itself. 7 Disruptions and distractions, illegible or missed orders, preparation of the wrong … Clerical errors, including misfiling, use of wrong forms or chart, and the inability to reach physicians … Application of the Universal Protocol with emphasis on surgical site marking – Wrong site, wrong procedure … , and wrong person surgeries are sentinel events that persist despite more than 30 professional groups … organizations and a continued increase in the occurrences of reported wrong site surgery cases and

76. Preparing for Ambulatory Computerized Prescriber Order Entry by Evaluating Preimplementation Medication Errors (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Devine.pdf
    July 01, 2003 - Inappropriate abbreviations (drug name, apothecary system, leading/trailing zeros, use of “u” for units) Wrong … information (wrong patient, wrong drug, wrong route, wrong dosage form, wrong dose, wrong strength, … wrong directions) Clinical criteria – patient allergy Clinical criteria – drug-drug interaction

77. Tool: Premortem (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/premortem-tool.docx
    January 01, 2017 - Things have gone completely wrong on a number of fronts. What could have caused this?” … Things have gone completely wrong on a number of fronts. What could have caused this?

78. Appendix VII: Public Comments Submitted Between March 7 and March 21, 2008 (continued) | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/report/apviia.html
    June 01, 2010 - Patient death or serious disability associated with a medication error (e.g., error involving the wrong … drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration

79. Reporting of Adverse Drug Events: Examination of a Hospital Incident Reporting System (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Desikan.pdf
    March 01, 2002 - dose 37 (15.8) 5 (12.5) 42 (15.6) Wrong drug 32 (14.0) 8 (20.0) 40 (14.9) Wrong infusion rate 31 … Dosing errors (wrong dose, extra dose, missed dose) were the predominant types of events reported. … More than 50 percent of the wrong infusion rate events were associated with heparin. … Insulin was associated with multiple types of events and accounted for all of the wrong dose, wrong … drug, wrong infusion rate, missed dose, and wrong patient events within the “hormones and synthetics

80. Four Moments of Antibiotic Decision Making Explained (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/four-moments-explained.pdf
    June 01, 2021 - care staff recognize that something is not quite right with the resident but aren’t clear on what is wrong