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psnet.ahrq.gov/node/38092/psn-pdf
September 24, 2008 - //psnet.ahrq.gov/issue/time-out-analysis
https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery
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psnet.ahrq.gov/node/36492/psn-pdf
June 09, 2011 - When surgery goes wrong: weighing up the risks.
June 9, 2011
Feinmann J. The Independent. … https://psnet.ahrq.gov/issue/when-surgery-goes-wrong-weighing-risks
This article reports on a husband's … https://psnet.ahrq.gov/issue/when-surgery-goes-wrong-weighing-risks
https://psnet.ahrq.gov/primer/human-factors-engineering
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psnet.ahrq.gov/node/35295/psn-pdf
July 24, 2008 - Buying the wrong medicine overseas.
July 24, 2008
Chase M.The Wall Street Journal. … Aug 2005
https://psnet.ahrq.gov/issue/buying-wrong-medicine-overseas
This article reports that in other … https://psnet.ahrq.gov/issue/buying-wrong-medicine-overseas
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psnet.ahrq.gov/node/49512/psn-pdf
May 01, 2006 - Neither should operating on
the wrong side of the right patient. … JCAHO has
recommended a series of steps to prevent wrong-site, wrong-side, and wrong-person procedures … To strengthen defenses against wrong-site and wrong-patient invasive procedures, hospitals should
implement … Sentinel Event Alert: A follow-up review of wrong site surgery. … Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.299_slideshow.ppt
May 01, 2013 - Spotlight Case July 2008
Spotlight Case
Right Regimen, Wrong Cancer: Patient Catches Medical Error … *
*
Case: Right Regimen, Wrong Cancer (2)
In the morning his bedside nurse for the day came in … *
*
Case: Right Regimen, Wrong Cancer (3)
Rather than the 3-day regimen for metastatic penile … own care and able to identify and intercept errors before they occur
*
*
Case: Right Regimen, Wrong … In choosing the chemotherapy regimen, the oncology fellow inadvertently chose the wrong paper order set—he
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psnet.ahrq.gov/node/39189/psn-pdf
April 16, 2018 - Neuromuscular blocking agents: reducing associated
wrong-drug errors. … April 16, 2018
https://psnet.ahrq.gov/issue/neuromuscular-blocking-agents-reducing-associated-wrong-drug-errors … https://psnet.ahrq.gov/issue/neuromuscular-blocking-agents-reducing-associated-wrong-drug-errors
https
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psnet.ahrq.gov/node/35893/psn-pdf
May 03, 2006 - Mix-up (wrong route of administration) of bladder
irrigation with intravenous (IV) infusions. … May 3, 2006
Veterans Affairs; National Center for Patient Safety
https://psnet.ahrq.gov/issue/mix-wrong-route-administration-bladder-irrigation-intravenous-iv-infusions … https://psnet.ahrq.gov/issue/mix-wrong-route-administration-bladder-irrigation-intravenous-iv-infusions
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psnet.ahrq.gov/node/41314/psn-pdf
September 27, 2016 - The Medical Apology: Making It Right When Things Go
Wrong.
September 27, 2016
Schulte MF, ed. … https://psnet.ahrq.gov/issue/medical-apology-making-it-right-when-things-go-wrong
Articles in this special … https://psnet.ahrq.gov/issue/medical-apology-making-it-right-when-things-go-wrong
https://psnet.ahrq.gov
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psnet.ahrq.gov/node/42294/psn-pdf
May 22, 2013 - Misdiagnosis is more common than drug errors or wrong-
site surgery.
May 22, 2013
Boodman SG. … https://psnet.ahrq.gov/issue/misdiagnosis-more-common-drug-errors-or-wrong-site-surgery
This newspaper … https://psnet.ahrq.gov/issue/misdiagnosis-more-common-drug-errors-or-wrong-site-surgery
https://psnet.ahrq.gov
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psnet.ahrq.gov/node/39179/psn-pdf
December 16, 2009 - psnet.ahrq.gov/issue/improving-operating-room-safety
https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery
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psnet.ahrq.gov/node/42310/psn-pdf
June 10, 2018 - Administering a saline flush "site unseen" can lead to a
wrong route error. … https://psnet.ahrq.gov/issue/administering-saline-flush-site-unseen-can-lead-wrong-route-error
Describing … https://psnet.ahrq.gov/issue/administering-saline-flush-site-unseen-can-lead-wrong-route-error
https:
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psnet.ahrq.gov/node/36451/psn-pdf
December 22, 2010 - issue/surgical-site-verification-through-z
https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery
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psnet.ahrq.gov/node/44573/psn-pdf
October 21, 2015 - Getting the diagnosis wrong.
October 21, 2015
Ofri D. New York Times. October 8, 2015. … https://psnet.ahrq.gov/issue/getting-diagnosis-wrong
This news article offers insights from a physician … https://psnet.ahrq.gov/issue/getting-diagnosis-wrong
https://psnet.ahrq.gov/primer/diagnostic-errors
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psnet.ahrq.gov/node/33652/psn-pdf
June 01, 2007 - Analysis of wrong-patient/wrong-site surgical errors led to
development of the New York preoperative … body part
Surgery performed on the wrong patient
Wrong surgical procedure performed on a patient … 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 … donor sperm or wrong egg
Environmental Events
Patient death or serious disability associated with
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psnet.ahrq.gov/node/49572/psn-pdf
October 01, 2008 - After further investigation, the intern
realized that the orthopedic team had evaluated the wrong patient—the … For example, the Universal
Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery … The wrong patient. Ann Intern Med. 2002;136:826-833. [go to PubMed]
4. Seiden SC, Barach P. … Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: are
they preventable? … Universal protocol for preventing wrong site, wrong procedure, wrong person
surgery.
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psnet.ahrq.gov/node/38822/psn-pdf
July 29, 2009 - 5th-anniversary-universal-protocol-pitfalls-and-pearls-revisited
https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery
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psnet.ahrq.gov/node/41929/psn-pdf
January 09, 2013 - quality-improvement-universal-protocol-use-office-based-gastrointestinal-procedure-units
https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery
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psnet.ahrq.gov/node/44481/psn-pdf
September 09, 2015 - When doctors get it wrong: misdiagnoses are getting a
closer look.
September 9, 2015
Olsen J. … https://psnet.ahrq.gov/issue/when-doctors-get-it-wrong-misdiagnoses-are-getting-closer-look
Diagnostic … https://psnet.ahrq.gov/issue/when-doctors-get-it-wrong-misdiagnoses-are-getting-closer-look
https://psnet.ahrq.gov
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psnet.ahrq.gov/issue/expanded-surgical-time-out-key-real-time-data-collection-and-quality-improvement
March 02, 2010 - January 17, 2019
Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong … December 22, 2010
Operating room briefings and wrong-site surgery. … May 27, 2010
Doing the "right" things to correct wrong-site surgery.
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psnet.ahrq.gov/node/40474/psn-pdf
July 02, 2011 - survey-use-time-out-protocols-emergency-medicine
https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery