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Showing results for "wrong".

  1. Improving Communication and Teamwork in the Surgical Environment Module | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/improving-slides.html
    October 01, 2020 - sites Wrong procedures Incorrect implants Missing equipment Mislabeling of specimens Delays … Operating room briefings and wrong-site surgery. … Reduced wrong-site surgeries and other adverse events. Increased staff morale. … site Wrong procedure Wrong/missing implant Wrong medications Unidentified allergy Wrong equipment … Operating room briefings and wrong-site surgery.

  2. Surgical never events in the United States. | PSNet

    psnet.ahrq.gov/issue/surgical-never-events-united-states
    September 10, 2014 - More than a decade ago, stories of wrong site surgeries and retained surgical objects galvanized … An incident of wrong-site surgery is discussed in an AHRQ WebM&M commentary . … April 8, 2020 Wrong-site surgery, retained surgical items, and surgical fires: a systematic … 2014 Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site

  3. Check the Wristband | PSNet

    psnet.ahrq.gov/web-mm/check-wristband
    August 03, 2009 - I apologized, explained she was in the wrong room, and asked that she return to the waiting area. … the wrong information. … When unchecked, such errors result in major patient misidentifications such as wrong site, wrong person … , or wrong procedure surgery.( 2 ) The Joint Commission on Accreditation of Healthcare Organization’s … The wrong patient. Ann Intern Med. 2002;136:826-33.[ go to PubMed ] 4.

  4. Theme Issue on Medical Error. | PSNet

    psnet.ahrq.gov/issue/theme-issue-medical-error
    October 01, 2024 - February 10, 2010 Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events

  5. Which Line: Ordering Provider or Proceduralist? | PSNet

    psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
    September 16, 2015 - When the patient presented for apheresis treatment, providers recognized that the wrong catheter had … patient or side, wrong exam or procedure (i.e., CT versus MRI), and incorrect details of how the exam … Evaluation of near-miss wrong-patient events in radiology reports. … Quality improvement guidelines for preventing wrong site, wrong procedure, and wrong person errors: application … of the Joint Commission "Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person

  6. The Inside of a Time Out | PSNet

    psnet.ahrq.gov/web-mm/inside-time-out
    March 01, 2004 - site surgery.( 3-5 ) Wrong Site Surgeries Debate over the exact incidence of wrong site surgery … Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. … Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: are they preventable? … Operating room briefings and wrong-site surgery. J Am Coll Surg. 2007;204:236-243. … August 26, 2011 Operating room briefings and wrong-site surgery.

  7. Context is Critical: Understanding When and Why Electronic Health Record-Related Safety Hazards Happen | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/context-critical-understanding-when-and-why-electronic-health-record-related
    January 01, 2023 - , wrong-medication, and wrong-route errors.  … Five error types were explored: wrong-route errors, wrong-weight errors, wrong-sided errors, free-text … order errors, and wrong-route-order errors. … EHR “bloat” For example, one analysis done was around acetaminophen (Tylenol) errors involving the wrong … These ‘wrong route’ errors can be catastrophic in some circumstances and are a focus of patient safety

  8. High-Alert Medication Learning Guides for Consumers. | PSNet

    psnet.ahrq.gov/issue/high-alert-medication-learning-guides-consumers
    April 30, 2019 - WebM&M Cases Medication Errors in Retail Pharmacies: Wrong … Patient, Wrong Instructions. … July 28, 2021 Getting the wrong person's medicine at the pharmacy: easy steps consumers … June 22, 2009 Buying the wrong medicine overseas. 

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854639/psn-pdf
    October 18, 2023 - Right Kind of Wrong: Why Learning to Fail can Teach us to Thrive. October 18, 2023 Edmondson A. … https://psnet.ahrq.gov/issue/right-kind-wrong-why-learning-fail-can-teach-us-thrive Despite the harm … https://psnet.ahrq.gov/issue/right-kind-wrong-why-learning-fail-can-teach-us-thrive https://psnet.ahrq.gov

  10. Doctor uses 'pre-flight' checklist. | PSNet

    psnet.ahrq.gov/issue/doctor-uses-pre-flight-checklist
    May 22, 2019 - More Related Resources Patient Safety Primers Wrong-Site … , Wrong-Procedure, and Wrong-Patient Surgery December 15, 2024 Facilitators … June 16, 2011 When surgery goes wrong: weighing up the risks.

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34636/psn-pdf
    June 14, 2011 - The wrong patient. June 14, 2011 Chassin MR, Becher EC. The wrong patient. … https://psnet.ahrq.gov/issue/wrong-patient This case study describes the events of a patient who underwent … https://psnet.ahrq.gov/issue/wrong-patient https://psnet.ahrq.gov/primer/root-cause-analysis

  12. Improving Communication and Teamwork in the Surgical Environment

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/improving/improving.pptx
    May 01, 2017 - sites Wrong procedures Incorrect implants Missing equipment Mislabeling of specimens Delays in surgery … Operating room briefings and wrong-site surgery. … Operating room briefings and wrong-site surgery. … site Wrong procedure Wrong/missing implant Wrong medications Unidentified allergy Wrong equipment … Operating room briefings and wrong-site surgery.

  13. ISMP Targeted Medication Safety Best Practices for Community Pharmacy. | PSNet

    psnet.ahrq.gov/issue/ismp-targeted-medication-safety-best-practices-community-pharmacy
    March 21, 2012 - This guidance shares evidence-based steps to address problems such as wrong patient errors and lack … WebM&M Cases Medication Errors in Retail Pharmacies: Wrong … Patient, Wrong Instructions.

  14. Dissecting communication barriers in healthcare: a path to enhancing communication resiliency, reliability, and patient safety. | PSNet

    psnet.ahrq.gov/issue/dissecting-communication-barriers-healthcare-path-enhancing-communication-resiliency
    July 12, 2023 - March 23, 2012 Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events

  15. AHRQ Safety Program for Ambulatory Surgery Final Report (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/ambulatory-surgery-report.pdf
    May 01, 2017 - site, wrong side, wrong patient, wrong procedure, wrong implant • Hospital transfer/admission from … Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant 287 0.72 (0.22–2.41) 0.60 Hospital … Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant 0.00% 0.01% 0.01% 0.01% 0.01% 0.00% … Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant 0.01% 0.00% 0.01% 0.01% 0.01% 0.00% … Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant 0.02% 0.01% 0.00% 0.00% 0.00% 0.00%

  16. Northwestern University | Digital Healthcare Research

    digital.ahrq.gov/organization/northwestern-university
    January 01, 2023 - Principal Investigator(s) Garcia, Sofia Penedo, Frank Preventing Wrong-Drug … and Wrong-Patient Errors With Indication Alerts in CPOE Systems Description This research … found a significant increase in problem placement rates, a modest increase in order abandonment (when a wrong … patient error was detected), and a slight increase in order retractions (when a wrong drug error was

  17. People, processes, health IT and accurate patient identification. | PSNet

    psnet.ahrq.gov/issue/people-processes-health-it-and-accurate-patient-identification
    April 11, 2018 - A WebM&M commentary discussed an incident involving a wrong-patient order in an electronic record … Delayed Diagnoses of Cancer July 31, 2023 Health information technology-related wrong-patient … More About The Topic Health Care Executives and Administrators Information Professionals Wrong

  18. Sentinel Event Data Summary. | PSNet

    psnet.ahrq.gov/issue/sentinel-event-statistics-1995-2019
    February 28, 2018 - Falls , wrong surgery and unintended retained foreign bodies were among the most frequently submitted … 2013 Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site … and Safety Professionals Information Professionals Retained Surgical Instruments and Sponges Wrong-Site

  19. Defining Diagnostic Error: A Scoping Review to Assess the Impact of the National Academies’ Report Improving Diagnosis in Health Care (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/topics/defining-diagnostic-error-a-scoping-review.pdf
    April 27, 2022 - using the Australian Patient Safety Foundation classification of error as “unintendedly delayed, wrong … However, both stud- ies operationalized error using a combination of pre-NASEM definitions—wrong and … Gupta et al22 United States Failure to diagnose, delay in diagnoses, wrong diagnosis, and other … Evidence of omission (failure to do the right thing) or commission (doing something wrong) exists at … Given that the components of accuracy (e.g., missed, wrong, misdiagnosis) and timeliness (e.g., delayed

  20. Knowledge Creation | Digital Healthcare Research

    digital.ahrq.gov/goal/knowledge-creation
    January 01, 2023 - Preventing Wrong-Drug and Wrong-Patient Errors With Indication Alerts in CPOE Systems Description … found a significant increase in problem placement rates, a modest increase in order abandonment (when a wrong … patient error was detected), and a slight increase in order retractions (when a wrong drug error was
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