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www.ahrq.gov/sites/default/files/wysiwyg/hai/cauti-tools/cauti-icu/preventing-cauti-icu-setting-facilitators-guide.docx
September 01, 2015 - 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
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Carayon.pdf
November 01, 2004 - follow-up after surgery), on various tools and
technologies used (e.g., H&P forms), and procedures (e.g., wrong-site … Carayon P, Schultz K, Hundt AS, Wrong site surgery
in outpatient settings: The case for a human factors
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Hoff.pdf
January 01, 2003 - (i.e., improper execution of
a proper clinical step or decision) rather than judgmental (i.e., the wrong … Maybe they
get caught before they happen, like giving someone a wrong drug
dose. … Let the attending tell you what you did wrong. … You excuse different things that
are done wrong a bit more, depending on the level of the (surgical)
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www.ahrq.gov/sites/default/files/2024-01/gallagher2-report.pdf
January 01, 2024 - …it helps the team
member figure out what went wrong and what we’re going to do
differently in the … Clinical Crossroads: A 62-year-old woman with skin cancer who experienced wrong site
surgery. … A 62-year-old woman with skin cancer who experienced wrong-site surgery: Review of
medical error.
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www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/dx-journey-presenter-notes.pdf
June 02, 2025 - struggling to put together all the pieces of how his dad’s diagnostic journey
could have gone so wrong
-
www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/dx-journey-mr-kane.pptx
June 02, 2025 - is struggling to put together all the pieces of how his dad’s diagnostic journey could have gone so wrong
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/booklets/appendectomy-booklet.pdf
November 01, 2023 - ■ If you feel sick to your stomach or you are throwing up
Call as soon as you think something is wrong
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www.ahrq.gov/patient-safety/settings/hospital/candor/demo-program/grants/appa.html
August 01, 2022 - Doing right by our patients when things go wrong in the ambulatory setting. … Selected Other Products Developed by Grantee
When Things Go Wrong in the Ambulatory Setting, a 4- … page tool published in 2013 that is a companion to When Things Go Wrong: Responding to Adverse Events … (2006)
When Things Go Wrong in the Ambulatory Setting video, available at https://vimeo.com/76550944
-
www.ahrq.gov/sites/default/files/2024-05/bruzzese3-report.pdf
January 01, 2024 - somewhat of a "black
box," with no clearly observable symptoms to sound a clinical alarm when something's wrong … Hear firsthand stories about its most
difficult cases, some involving surgical fires, wrong-site surgery
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospitalresourcelist.pdf
January 01, 2019 - Many things can go wrong, however, and plenty of research has shown botched
patient handoffs can be … • Eliminating Wrong Site Surgery and Procedure Events.
• MHS Leadership Engagement.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/engaging-nurse-physician-patient-transcript.docx
June 02, 2025 - Again, the most important component of this process is that if focuses on what went wrong not who did … something wrong.
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/report/apv.html
June 01, 2010 - Forum
Residential care
Patient death or serious disability associated with medication error (wrong
-
www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/environmental-scan-programs/envptscan.pdf
June 01, 2013 - Critical Lab Results 0
413 Fatigue and Sleep Deprivation 13
411 Identification Errors 18
443 -- Wrong … Patient 7
444 -- Wrong-Site Surgery 12
426 Medical Complications 26
429 -- Delirium 2
427 … Intraoperative Complications 12
440 ---- Retained Surgical Instruments and Sponges 0
447 ---- Wrong-Site
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/vae/vaesurveillance-facguide.docx
January 01, 2017 - When the definitions are objective, unit staff can spend time focusing on what went wrong and how to
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/educational-bundles/communication-and-teamwork/communication-strategies.pptx
September 01, 2016 - Peck but Mary just started working on the unit with Jessica and doesn’t want to start off on the wrong
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/impguide.html
December 01, 2014 - What is likely to go wrong? What approach would you take to address these issues?
-
www.ahrq.gov/sites/default/files/publications2/files/interimhacrate2014_cx.pdf
November 19, 2015 - Saving Lives and Saving Money: Hospital-Acquired Conditions Update - Interim Data From National Efforts To Make Care Safer, 2010-2014
Saving Lives and Saving Money: Hospital-Acquired Conditions
Update
Interim Data From National Efforts To Make Care Safer, 2010-2014
Summary
Interim estimates for 2014 show a sust…
-
www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module4/mod4-facguide.html
March 01, 2017 - These fears can include the fear of feeling embarrassed, or being ridiculed, or being wrong.
-
www.ahrq.gov/sites/default/files/publications/files/interimhacrate2014_2.pdf
November 19, 2015 - Saving Lives and Saving Money: Hospital-Acquired Conditions Update - Interim Data From National Efforts To Make Care Safer, 2010-2014
Saving Lives and Saving Money: Hospital-Acquired Conditions
Update
Interim Data From National Efforts To Make Care Safer, 2010-2014
Summary
Interim estimates for 2014 show a s…
-
www.ahrq.gov/hai/cauti-tools/archived-webinars/engaging-nurse-physician-patient-transcript.html
December 01, 2017 - Again, the most important component of this process is that if focuses on what went wrong not who did … something wrong.