-
psnet.ahrq.gov/web-mm/are-you-mrs-issue-identification-over-telephone
January 01, 2016 - of wrong patient errors can be appreciated by looking at medication errors. … No simple fix will prevent all wrong patient errors. … However, double-checking identification will not solve all wrong patient errors. … Completely eliminating wrong patient errors will be a long journey. … Oops, sorry, wrong patient!
-
psnet.ahrq.gov/node/60180/psn-pdf
April 01, 2020 - -
service-board
Operating room list errors are often cited as leading to wrong-side, wrong-site or … wrong-procedure errors. … , wrong-site or wrong-procedure surgeries were performed during the period, 0.29% of cases
(86 cases … Wrong-side list errors accounted for the majority of all list errors (72%). … https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery
-
digital.ahrq.gov/sites/default/files/docs/citation/r21hs023704-adelman-final-report-2019.pdf
January 01, 2019 - The primary outcome was wrong-patient order sessions, including at least one wrong-
patient order identified … Wrong-patient order sessions per 100,000 122.5 139.2 1.00 (0.68 to 1.46) 1.00
Wrong-patient order … Critical care
Wrong-patient orders per 100,000 117.7 120.8
Wrong-patient orders 215 301
Total … orders 182,698 249,252
Pediatrics
Wrong-patient orders per 100,000 54.4 58.6
Wrong-patient … Wrong-patient order sessions per 100,000 112.2 150.5 0.73 (0.50 to 1.06) .10
Wrong-patient order
-
psnet.ahrq.gov/issue/duplication-surgical-site-marking
November 18, 2016 - March 29, 2023
Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient … June 23, 2021
Incidence of wrong-site surgery list errors for a 2-year period in a single … April 1, 2020
Wrong-site surgery. … Cheek
March 1, 2012
Application of human error theory in case analysis of wrong … Site, Wrong Procedure and Wrong Person Surgery.
-
psnet.ahrq.gov/issue/surgical-confusions-ophthalmology
November 16, 2022 - The most common adverse events included wrong lens implants and wrong eye operations, and the authors … June 15, 2016
Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person … December 22, 2010
Operating room briefings and wrong-site surgery. … July 28, 2010
Doing the "right" things to correct wrong-site surgery.
-
psnet.ahrq.gov/issue/evolution-patient-safety-procedures-oral-surgery-department
November 16, 2022 - Reporting and avoidance of “ never events ,” such as a wrong tooth extraction, is important for providing … Improving Diagnostic Safety and Quality
April 26, 2023
Wrong … Site Surgery - Wrong Patient: Invasive Procedures in Outpatient Settings. … June 16, 2021
Wrong Site Surgery–Wrong Tooth Extraction. … January 13, 2021
Incidence of wrong-site surgery list errors for a 2-year period in a
-
psnet.ahrq.gov/issue/process-changes-increase-compliance-universal-protocol-bedside-procedures
December 01, 2014 - Site, Wrong Procedure and Wrong Person Surgery. … February 9, 2011
The wrong foot, and other tales of surgical error. … August 18, 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.
-
psnet.ahrq.gov/node/846759/psn-pdf
March 29, 2023 - A contemporary analysis of closed claims related to
wrong site surgery. … A contemporary analysis of closed claims related to wrong site surgery. … https://psnet.ahrq.gov/issue/contemporary-analysis-closed-claims-related-wrong-site-surgery
Wrong-site … /primer/wrong-site-wrong-procedure-and-wrong-patient-surgery
https://psnet.ahrq.gov/primer/never-events … web-mm/two-wrongs-dont-make-right-kidney
https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery
-
psnet.ahrq.gov/issue/medical-culture-about-errors-may-be-changing
September 19, 2018 - April 6, 2016
The pain of wrong site surgery. … July 6, 2011
Wrong body part, wrong patient surgeries continue despite new procedures … June 8, 2011
The wrong foot, and other tales of surgical error. … August 13, 2008
Hospital tells of surgery on wrong side. … August 6, 2008
'Wrong site' surgeries on the rise.
-
psnet.ahrq.gov/node/61096/psn-pdf
November 04, 2020 - Wrong drug and wrong dose dispensing errors identified
in pharmacist professional liability claims. … https://psnet.ahrq.gov/issue/wrong-drug-and-wrong-dose-dispensing-errors-identified-pharmacist-
professional-liability … This
study used malpractice claims data to explore trends in wrong drug and wrong dose dispensing errors … Between 2013 and 2018, the percentage of claims associated with both wrong drug and wrong dose
dispensing … https://psnet.ahrq.gov/issue/wrong-drug-and-wrong-dose-dispensing-errors-identified-pharmacist-professional-liability
-
psnet.ahrq.gov/node/867228/psn-pdf
December 04, 2024 - Risk factors for wrong-patient medication orders in the
emergency department. … Risk factors for wrong-patient medication orders in the
emergency department. … https://psnet.ahrq.gov/issue/risk-factors-wrong-patient-medication-orders-emergency-department
Wrong-patient … https://psnet.ahrq.gov/issue/risk-factors-wrong-patient-medication-orders-emergency-department
https: … //psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery
https://psnet.ahrq.gov/issue
-
psnet.ahrq.gov/web-mm/turn-other-cheek
October 26, 2010 - The Joint Commission defines wrong-site surgery as any surgery performed on the wrong site or the wrong … The patient in this case self-identified the wrong surgical site. … A follow-up review of wrong site surgery. Sentinel Event Alert. December 5, 2001. … Outcome of 6 years of protocol use for preventing wrong site office surgery. … July 28, 2021
Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient
-
psnet.ahrq.gov/issue/surgical-procedure-grid-safety-and-operating-room-communication-multisite-surgery
June 17, 2014 - Wrong-patient and wrong-site surgeries are considered never events. … June 21, 2017
Wrong site surgery: a critical incident analysis of a near miss. … September 12, 2012
A 62-year-old woman with skin cancer who experienced 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.
-
psnet.ahrq.gov/issue/when-things-go-wrong-voices-patients-and-families
November 19, 2015 - Audiovisual
When Things Go Wrong: Voices of Patients and Families. … Citation Text:
When Things Go Wrong: Voices of Patients and Families. … Copy URL
Cite
Citation
Citation Text:
When Things Go Wrong
-
psnet.ahrq.gov/issue/ventilator-associated-pneumonia-wrong-quality-measure-benchmarking
March 28, 2012 - Commentary
Ventilator-associated pneumonia—the wrong quality measure for benchmarking … Ventilator-associated pneumonia—the wrong quality measure for benchmarking. … Ventilator-associated pneumonia—the wrong quality measure for benchmarking.
-
psnet.ahrq.gov/web-mm/wrong-blade-lack-familiarity-pediatric-emergency-equipment
June 01, 2018 - The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment
Citation Text: … The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment. PSNet [internet]. … The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment. PSNet [internet]. … The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment. PSNet [internet].
-
psnet.ahrq.gov/node/33561/psn-pdf
September 15, 2024 - site
Surgery or other invasive procedure performed on the wrong patient
Wrong surgical or other invasive … drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of
administration … https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events
https://psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event … https://psnet.ahrq.gov/issue/medicare-says-it-wont-cover-hospital-errors
https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery … https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery
https://psnet.ahrq.gov
-
psnet.ahrq.gov/issue/patient-safetyquality-improvement-primer
September 13, 2017 - Otolaryngology-head and neck surgery is vulnerable to wrong site errors and other challenges present … Copy Citation
Related Resources From the Same Author(s)
Wrong-site surgery … May 10, 2023
A contemporary analysis of closed claims related to wrong site surgery. … March 29, 2023
Wrong Site Surgery–Wrong Tooth Extraction. … January 20, 2021
Incidence of wrong-site surgery list errors for a 2-year period in a
-
psnet.ahrq.gov/issue/use-temporary-names-newborns-and-associated-risks
December 21, 2017 - Wrong-patient errors are considered to be never events . … December 21, 2017
Risk of wrong-patient orders among multiple vs singleton births in … May 29, 2019
Understanding and preventing wrong-patient electronic orders: a randomized … January 17, 2024
Wrong-patient orders in obstetrics. … Newborn naming conventions and wrong-patient errors.
-
psnet.ahrq.gov/node/860724/psn-pdf
January 17, 2024 - Retrospective cohort study of wrong-patient imaging
order errors: how many reach the patient? … Retrospective cohort study of wrong-patient imaging
order errors: how many reach the patient? … https://psnet.ahrq.gov/issue/retrospective-cohort-study-wrong-patient-imaging-order-errors-how-many- … https://psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors
https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery … https://psnet.ahrq.gov/issue/evaluation-near-miss-wrong-patient-events-radiology-reports