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Total Results: 725 records

Showing results for "wrong".

81. Final Progress Report: Developing Definitions, Measurement Strategies, and Links to Medication Errors (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/savage-report.pdf
    January 01, 2024 - Potential patient impact coded P=Wrong Patient; T=Wrong Time; R=Wrong Route; M=Wrong Medication (Drug … ); D=Wrong Dose). … Frequent checking of possible locations Infrequent T - Extra time to administer 5 Order placed in wrong … Take medication from code cart Half of time (when codes occur) P,M,D,T,R - Increased risk of wrong … medication, wrong dose 3 Medication not where expected R - Calls to pharmacy R - Call to Nurse

82. Final Progress Report: Malpractice Insurers’ Medical Error Surveillance and Prevention Study (MIMESPS) (pdf file)
    www.ahrq.gov/sites/default/files/2024-09/studdert-report.pdf
    January 01, 2024 - focused on recognized patient safety problems (e.g., retained foreign instruments after surgery, wrong … failure of a planned action to be completed as intended (i.e., error of execution) or the use of a wrong … may have been disinclined to credit the system’s findings (or even pleased to conclude that it was wrong … In some cases (e.g., missed breast cancer, wrong site surgery) these subanalyses involve use of data … Incidence, patterns, and prevention of wrong-site surgery (accepted for publication: Surgery, 2005)

83. Why Checklists for Diagnosis Are Not Performing as Expected | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxchecklists-5.html
    September 01, 2020 - task but erred only in the execution (e.g., forgetting a step in the preoperative process, marking the wrong

84. TeamSTEPPS® Diagnosis Improvement: Infographic (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/dxsafety-infographic.pdf
    February 01, 2022 - communication failures occur across all settings.4 Inpatient 22% Outpatient 55% Inappropriate testing, wrong

85. Innovative Use of Technology in Primary Care Delivery - Slide Presentation (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/webinars/innovative-use-pcr-091423.pdf
    September 14, 2023 - developers made prototype changes within and between sessions Example Prompts “Where can things go wrong … “What have you done to keep things from going wrong?” … can be very dangerous if he gets too much… I’ve even caught medications that someone has drawn up wrong … , or even medications that I’ve drawn up wrong.”

86. Preventing-Cauti-Icu-Setting-Module 2-Speaker-Notes (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/cauti-tools/cauti-icu/preventing-cauti-icu-setting-module_2-speaker-notes.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

87. Terminology and Language Used by Patients and Caregivers | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-terminology8.html
    April 01, 2025 - When things go wrong, they may speak not of errors, but rather mistakes, problems, mishaps, misunderstandings

88. Denver Health: How a Safety Net System Maximizes Its Value (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/lhs/lhs_case_studies_denver_health.pdf
    April 01, 2019 - For example, asking what can be learned when something goes wrong led to the development of a systemwide … this perceived problem, they closely examined their data and discovered that their assumption was wrong … Rather than assuming something was going wrong in surgery, they stepped back and looked at their patient

89. 3 Key Takeaways from the July 2018 Webcast: New SOPS HIT Patient Safety Supplemental Items for Hospitals (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospital/healthitwebinar/sops-hit-webcast-keytakeaways.pdf
    August 01, 2018 - information in their EHR was inaccurate 32% discovered that information was entered into the wrong

90. 155-Performing-Premortem-Project-Assessment (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/155-performing-premortem-project-assessment.docx
    October 01, 2024 - What could have gone wrong? … What could have gone wrong? Can you foresee staffing issues? Educational issues?

91. 109-Performing-Premortem-Project-Assessment-Fg (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/109-performing-premortem-project-assessment-fg.docx
    April 01, 2025 - What could have gone wrong? … What could have gone wrong? Can you foresee staffing issues? Educational issues?

92. Final Progress Report: Proactive Risk Assessment of Primary Care of the Elderly (pdf file)
    www.ahrq.gov/sites/default/files/2024-12/karsh-report.pdf
    January 01, 2024 - treatment decision, and wrong diagnosis as causes of errors. 13 Literature reviews found basically the … -Child with asthma exacerbation receives wrong med and dies. (Real example: a pregnant woman at St. … -Patient has to call back to inquire about a medication error when doctor writes wrong script. … , and physician commits suicide. 9 Quit medicine -Physician administers wrong medication, patient dies … You intended to do the right thing but did the wrong thing.

93. Appendix O. Nursing Focus Group Guides | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/findings/final-reports/ssi/ssiapo.html
    April 01, 2018 - There are no right or wrong answers, and I will facilitate the group so that we'll have a chance to hear … There are no right or wrong answers, and I will facilitate the group so that we'll have a chance to hear

94. AHRQ Expands Its Repertoire to Eliminate Diagnostic Errors | Agency for Healthcare Research and Quality
    www.ahrq.gov/news/blog/ahrqviews/eliminate-diagnostic-errors.html
    August 01, 2022 - follow a diagnostic error – a diagnosis that is either delayed, poorly communicated, or just plain wrong

95. BLADDER SCAN – POLICY #2202 12/11/06 (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/educational-bundles/urine-culturing/whento-order/urine-cultures-worksheet.docx
    March 01, 2017 - What went wrong during this interaction between Nurse Nohai and Dr. Killbug? 2. What could Dr.

96. Tool 6. Worksheet: Establishing Protocols for BMI Screening | Agency for Healthcare Research and Quality
    www.ahrq.gov/ncepcr/tools/obesity/obpcp-tool6.html
    May 01, 2014 - Scale in "wrong location?" Draft BMI screening protocols.

97. Final Progress Report: Evaluate the Effects of the Massachusetts Reporting System (pdf file)
    www.ahrq.gov/sites/default/files/2024-11/ridley-report.pdf
    January 01, 2024 - Surgery performed on the wrong body part 8.2 B. Surgery performed on the wrong patient 1.4 C. … Wrong surgical procedure performed on a patient 0.9 D. … Infant discharged to wrong person 0.0 B. … Patient death or serious disability associated with a medication error (e.g., errors involving the wrong … drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration

98. 2024 Results for the AHRQ Surveys on Patient Safety Culture® (SOPS®) Diagnostic Safety Supplemental Item Set for Medical Offices (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/medical-office-diagnostic-safety-database-report-2024.pdf
    January 01, 2024 - reporting system that has a specific coded category to document diagnostic errors such as missed, wrong … (Item DXC3, NA/DK/MI = 50%) 56 When a missed, wrong, or delayed diagnosis happens in this office, … (Item DXC3) 56% 68% 49% 55% When a missed, wrong, or delayed diagnosis happens in this office, we are … (Item DXC3) 54% 54% 45% 59% 74% 56% When a missed, wrong, or delayed diagnosis happens in this office … (Item DXC3) 45% 58% 54% When a missed, wrong, or delayed diagnosis happens in this office, we are informed

99. Standardizing Ambulatory Care Procedures in a Public Hospital System to Improve Patient Safety (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Kleinpeter.pdf
    January 01, 2004 - Eliminate wrong-site, wrong-patient, wrong- procedure surgery 4. Target surgery 5. … Target surgery The NPSGs goal to eliminate the wrong-site, wrong-patient, and wrong- procedure was

100. We Must Not Underestimate the Impacts of Gun Violence on Healthcare Workers | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/blog/ahrqviews/impacts-gun-violence.html
     March 01, 2023 - We owe it to each other to make our grief known and speak out about this wrong.