Results

Total Results: 1,736 records

Showing results for "wrong".

1441. Misplaced Nasogastric Tube Resulting in Aspiration | PSNet
      psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
      August 01, 2009 - October 27, 2022 WebM&M Cases Wrong Catheter in

1442. Anchoring Bias With Critical Implications | PSNet
      psnet.ahrq.gov/web-mm/anchoring-bias-critical-implications
      June 15, 2022 - From possible to probable to sure to wrong—premature closure and anchoring in a complicated case.

1443. Understanding CancelRx: Impact on Clinical Workflows, Medication Safety Risks, and Patient Outcomes – Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/r21hs026584-pitts-final-report-2022.pdf
      January 01, 2022 - adjustment, and failure to communicate discontinuation of previous prescriptions may result in the wrong

1444. Program Overview: Slide Presentation | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/surgery/modules/on-boarding/overview-slides.html
      December 01, 2017 - Things have gone completely wrong on a number of fronts.

1445. Engaging Senior Executives: Facilitator Notes | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/surgery/modules/on-boarding/sr-exec-slides.html
      December 01, 2017 - Requires Technical and Adaptive Efforts Say: Despite numerous technical approaches to improve wrong-site

1446. Don’t Wait to Collect an Accurate Weight: A Case of Subtherapeutic Insulin Therapy | PSNet
      psnet.ahrq.gov/web-mm/dont-wait-collect-accurate-weight-case-subtherapeutic-insulin-therapy
      July 01, 2008 - setting. 5 In a study of 326 pediatric dose-related safety events from Pennsylvania, 15% involved using wrong

1447. Reducing Preventable Patient Harm Due to Retained Surgical Items: The RSI Bundle | PSNet
      psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle
      July 23, 2024 - Wrong-site surgery, retained surgical items, and surgical fires: a systematic review of surgical never

1448. Hypoxemia after Emergency Intubation | PSNet
      psnet.ahrq.gov/web-mm/hypoxemia-after-emergency-intubation
      March 24, 2019 - April 26, 2023 WebM&M Cases The Wrong Blade: A

1449. Airway Obstruction during Anterior Cervical Spine Surgery | PSNet
      psnet.ahrq.gov/web-mm/airway-obstruction-during-anterior-cervical-spine-surgery
      January 29, 2021 - Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong

1450. Final Data From National Efforts To Make Care Safer, 2010-2014 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/2014FinalHACreport4Web-13Dec2016.pdf
      December 01, 2016 - Final Data From National Efforts To Make Care Safer, 2010-2014 December 2016 Saving Lives and Saving Money: Hospital-Acquired Conditions Update Final Data From National Efforts To Make Care Safer, 2010-2014 Summary Final estimates for 2014 show a sustained 17 percent decline in hospital-acquired conditions…

1451. Chapter 1. The Framework for Improvement | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/vtguide/guide1.html
      February 01, 2016 - There are many ways to get this wrong, and only two or three ways that seem to work reliably across a

1452. How Do Providers Recover From Errors? | PSNet
      psnet.ahrq.gov/web-mm/how-do-providers-recover-errors
      May 22, 2024 - SPOTLIGHT CASE How Do Providers Recover From Errors? Citation Text: West CP. How Do Providers Recover From Errors?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar Bi…

1453. Appendix A. Grantee Profiles | Agency for Healthcare Research and Quality
      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

1454. Using Information Technology for Patient-Centered Communication and Decisionmaking about Medications - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/r18hs017220-wolf-final-report-2012.pdf
      January 01, 2012 - call to see if they filled their prescription, and secondary adherence was considered as missed or wrong … also treated as a binary variable with 80% or greater adherence in the past week (based on missed/wrong

1455. Improving Patient Safety in Hospitals: A Resource List for Users of the AHRQ Hospital Survey on Patient Safety Culture (pdf file)
      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.

1456. Health Information Technology Evaluation Toolkit: 2009 Update (pdf file)
      digital.ahrq.gov/sites/default/files/docs/page/health-information-technology-evaluation-toolkit-2009-update.pdf
      January 01, 2009 - Proportion of medications leaving the pharmacy containing errors: wrong medication, wrong dose, … wrong strength or form, wrong quantity, or a safety violation.

1457. Archived: Final Evidence Summary: Impaired Visual Acuity in Older Adults: Screening | United States Preventive Services Taskforce
      www.uspreventiveservicestaskforce.org/uspstf/document/final-evidence-summary50/impaired-visual-acuity-in-older-adults-screening-2009
      July 15, 2009 - intervention reviewed in full evidence report: 48 Included in systematic reviews: 52 Wrong … intervention: 39 Wrong outcome: 28 Wrong population: 34 Wrong study design or

1458. Despite Clues, Failed to Rescue | PSNet
      psnet.ahrq.gov/web-mm/despite-clues-failed-rescue
      August 02, 2015 - October 1, 2011 WebM&M Cases Bad Writing, Wrong

1459. Appendix V: Tested Measures by DRA Domain | Agency for Healthcare Research and Quality
      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

1460. CHII Costs (ppt file)
      digital.ahrq.gov/sites/default/files/docs/page/ADAMS_3_I.ppt
      January 01, 2013 - Crossing the Quality Chasm, 2000 Right Wrong “… 44,000 to 98,000 deaths ...”