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psnet.ahrq.gov/issue/using-near-misses-analysis-prevent-wrong-site-surgery
April 24, 2018 - Study
Using "near misses" analysis to prevent wrong-site surgery. … Using "near misses" analysis to prevent wrong-site surgery. … Using "near misses" analysis to prevent wrong-site surgery. … June 15, 2011
Operating room briefings and wrong-site surgery. … July 28, 2010
Wrong site surgery near misses and actual occurrences.
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psnet.ahrq.gov/issue/assessment-implementation-national-patient-safety-alert-reduce-wrong-site-surgery
March 28, 2011 - Study
Assessment of the implementation of a national patient safety alert to reduce wrong … Assessment of the implementation of a national patient safety alert to reduce wrong site surgery. … Wrong-site surgery is a rare yet devastating outcome. … Assessment of the implementation of a national patient safety alert to reduce wrong site surgery. … March 29, 2012
Wrong site surgery.
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psnet.ahrq.gov/issue/development-and-implementation-subcutaneous-insulin-pen-label-bar-code-scanning-protocol
October 19, 2022 - Development and implementation of a subcutaneous insulin pen label bar code scanning protocol to prevent wrong-patient … Development and Implementation of a Subcutaneous Insulin Pen Label Bar Code Scanning Protocol to Prevent Wrong-Patient … administration and a standardized electronic health record–integrated workflow to successfully reduce wrong-patient … May 18, 2022
Risk of wrong-patient orders among multiple vs singleton births in the neonatal … September 26, 2016
A crack in our best armor: "wrong patient" injections from insulin
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psnet.ahrq.gov/issue/patient-participation-surgical-site-marking-can-be-additional-tool-help-avoid-wrong-site
March 14, 2022 - Patient participation in surgical site marking: can this be an additional tool to help avoid wrong-site … Patient participation in surgical site marking: can this be an additional tool to help avoid wrong-site … Wrong-site surgeries remain a persistent safety issue , despite extensive efforts by regulatory bodies … While only a few patients committed an overt error (i.e., signing the wrong site), the suboptimal adherence … Patient participation in surgical site marking: can this be an additional tool to help avoid wrong-site
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digital.ahrq.gov/program-overview/research-stories/displaying-patient-photos-medical-records-reduces-errors-improves
January 01, 2023 - Wrong patient orders can harm patients While digital solutions like computerized provider order entry … systems have reduced medical errors and improved patient safety, the risk of placing orders for the wrong … “Orders placed on the wrong patient should be a ‘never event,’ as in it should never happen,” said Dr … Wrong patient orders were identified by using the Wrong-Patient Retract-and-Reorder Measure (WP-RAR), … a validated, reliable, and automated method for identifying wrong-patient orders developed by Dr.
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psnet.ahrq.gov/issue/multistep-approach-improving-biopsy-site-identification-dermatology-physician-staff-and
October 12, 2022 - March 19, 2019
View More
Related Resources
Insurance claims for wrong-side … , wrong-organ, wrong-procedure, or wrong-person surgical errors: a retrospective study for 10 years. … January 17, 2019
Using "near misses" analysis to prevent wrong-site surgery. … Other Cheek
March 1, 2012
Outcome of 6 years of protocol use for preventing wrong … October 4, 2011
Wrong-patient, wrong-site procedures persist despite safety protocol.
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psnet.ahrq.gov/innovation/standardized-marking-procedure-ent-operations-prevent-wrong-site-surgery-development
February 01, 2013 - EMERGING INNOVATIONS
A standardized marking procedure for ENT operations to prevent wrong-site surgery … A standardized marking procedure for ENT operations to prevent wrong-site surgery: development, establishment … Although wrong-site surgeries are rare , the consequences can be very serious . … April 19, 2023
Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient … June 15, 2011
Wrong-site sinus surgery in otolaryngology.
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psnet.ahrq.gov/issue/electronic-patient-identification-sample-labeling-reduces-wrong-blood-tube-errors
September 20, 2012 - Emerging Classic
Electronic patient identification for sample labeling reduces wrong … Electronic patient identification for sample labeling reduces wrong blood in tube errors. … Wrong-patient errors in blood transfusion can lead to serious patient harm. … This pre–post study examined the impact of barcode labeling on the rate of wrong blood in tube errors … Electronic patient identification for sample labeling reduces wrong blood in tube errors.
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digital.ahrq.gov/ahrq-funded-projects/preventing-wrong-drug-and-wrong-patient-errors-indication-alerts-cpoe-systems/citation/indication
January 01, 2023 - pubmed.ncbi.nlm.nih.gov/34957491/
Principal Investigator
Lambert, Bruce
Project Name
Preventing Wrong-Drug … and Wrong-Patient Errors With Indication Alerts in CPOE Systems
Technology
Clinical Decision
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psnet.ahrq.gov/node/33576/psn-pdf
December 15, 2024 - Wrong-Site, Wrong-Procedure, and Wrong-Patient
Surgery
December 15, 2024
Wrong-Site, Wrong-Procedure … https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery
PSNet primers are … These "wrong-site, wrong-procedure, wrong-patient errors" (WSPEs) are rightly termed never
events—errors … Preventing Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery
Early efforts to prevent WSPEs focused … Current Context
Wrong-patient, wrong-site, and wrong-procedure errors are all considered never events
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digital.ahrq.gov/ahrq-funded-projects/assess-risk-wrong-patient-errors-emr-allows-multiple-records-open/citation/assess
January 01, 2023 - Effect of number of open charts on intercepted wrong-patient medication orders in an emergency department … Effect of number of open charts on intercepted wrong-patient medication orders in an emergency department … 29025090
Principal Investigator
Adelman, Jason Stuart
Project Name
Assess Risk of Wrong-Patient
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psnet.ahrq.gov/node/844051/psn-pdf
February 08, 2023 - Insurance claims for wrong-side, wrong-organ, wrong-
procedure, or wrong-person surgical errors: a … Insurance claims for wrong-side, wrong-organ, wrong-procedure,
or wrong-person surgical errors: a retrospective … https://psnet.ahrq.gov/issue/insurance-claims-wrong-side-wrong-organ-wrong-procedure-or-wrong-person- … https://psnet.ahrq.gov/issue/insurance-claims-wrong-side-wrong-organ-wrong-procedure-or-wrong-person-surgical-errors … https://psnet.ahrq.gov/issue/insurance-claims-wrong-side-wrong-organ-wrong-procedure-or-wrong-person-surgical-errors
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Faltz_56.pdf
March 27, 2008 - Introduction
Wrong-patient, wrong-side, or wrong-site surgical and invasive procedures, while unusual … NYPORTS codes related to wrong-side, wrong-patient, and wrong-
procedure surgery and other invasive … Surgery on the
wrong side of the body, wrong site, or wrong patient led the list. … 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?
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psnet.ahrq.gov/issue/it-left-eye-right
September 06, 2023 - August 2, 2015
Using "near misses" analysis to prevent wrong-site surgery. … December 21, 2014
Application of human error theory in case analysis of wrong procedures … June 15, 2011
Wrong site surgery. … Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong … Site, Wrong Procedure and Wrong Person Surgery.
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psnet.ahrq.gov/web-mm/mark-my-tooth
June 01, 2014 - or wrong-site surgery performed by its 4300 members. … Site, Wrong Procedure, Wrong Person Surgery" into daily clinical practice. … surgery, including wrong-site tooth extraction. … Wrong-site surgery: a preventable complication. Clin Orthop Relat Res. 2005;433:26-29. … January 17, 2019
Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong
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www.ahrq.gov/sites/default/files/2024-01/higginson-report.pdf
January 01, 2024 - drug, wrong dose, wrong resident, and omitted drug/dose. … Drug 5.9 7.0
Wrong Dose 2.8 2.8
Wrong Resident 1.0 0.7
Omission 70 70
Wrong Resident:
Figure 2. … dose, wrong drug, and wrong resident. … Wrong dose 15
Wrong
strength
8/4481 or .002
Wrong
quantity
9/4481 or .002
Wrong
Patient
1.9 0.4 … Dose
Overdose 4.8
Underdose 1.9
Wrong form .3 1.8 0.2 6.2
Wrong dose 7.542 32.042
Wrong
strength
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psnet.ahrq.gov/issue/when-surgeon-should-just-say-im-sorry
February 05, 2014 - November 16, 2016
When doctors get the wrong patient. … November 28, 2016
Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong … May 21, 2013
The wrong foot, and other tales of surgical error. … November 25, 2009
Hospital tells of surgery on wrong side. … August 6, 2008
'Wrong site' surgeries on the rise.
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psnet.ahrq.gov/issue/getting-surgery-right
February 15, 2011 - April 30, 2014
Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person … Site, Wrong Procedure and Wrong Person Surgery. … December 22, 2010
Operating room briefings and wrong-site surgery. … July 28, 2010
Avoiding wrong site surgery: a systematic review. … May 26, 2010
Wrong site surgery near misses and actual occurrences.
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psnet.ahrq.gov/issue/enhanced-time-out-improved-communication-process
October 19, 2022 - The Universal Protocol requires hospitals to adopt time outs as a strategy to prevent wrong-site surgeries … More
Related Resources
Patient Safety Primers
Wrong-Site … , Wrong-Procedure, and Wrong-Patient Surgery
December 15, 2024
Facilitators … April 27, 2016
Wrong site surgery: a critical incident analysis of a near miss. … December 22, 2010
Avoiding wrong site surgery: a systematic review.
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psnet.ahrq.gov/issue/preoperative-site-marking-are-we-adhering-good-surgical-practice
August 02, 2017 - Wrong-site surgery represents a never event . … May 10, 2023
A contemporary analysis of closed claims related to wrong site surgery. … March 29, 2023
Insurance claims for wrong-side, wrong-organ, wrong-procedure, or wrong-person … August 11, 2021
Wrong Site Surgery–Wrong Tooth Extraction. … January 20, 2021
Incidence of wrong-site surgery list errors for a 2-year period in a