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Total Results: 1,736 records

Showing results for "wrong".

201. Rates of serious surgical errors in California and plans to prevent recurrence. | PSNet
     psnet.ahrq.gov/issue/rates-serious-surgical-errors-california-and-plans-prevent-recurrence
     March 09, 2022 - Retained foreign objects were the most commonly reported never event (66.2%), followed by wrong site … or wrong patient (15.5%), and surgical burns (7.7%).

202. Identification of common themes from never events data published by NHS England. | PSNet
     psnet.ahrq.gov/issue/identification-common-themes-never-events-data-published-nhs-england
     April 07, 2021 - 2020 in the National Health Services and categorized 51 common never events into four categories – wrong … site surgery (40% of events); retained foreign objects post-procedure (28%); wrong implant/prosthesis

203. Shachak A et al. 2009 "Primary care physicians' use of an electronic medical record system: a cognitive task analysis." | Digital Healthcare Research
     digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/shachak-et-al-2009
     January 01, 2009 - sometimes resulted in errors, such as the selection of incorrect medication or the input of data into the wrong … Typical errors reported by most study participants (>60%) were typos, adding information to the wrong … above or below the desired item...Study participants described two common scenarios for adding to the wrong … "A number of study participants reported discovering they had written in the wrong patient's chart only … Similarly, study participants sometimes realized they had prescribed the wrong medication when concerned

204. Two words can soothe patients who have been harmed: we're sorry. | PSNet
     psnet.ahrq.gov/issue/two-words-can-soothe-patients-who-have-been-harmed-were-sorry
     July 26, 2017 - December 14, 2016 Misdiagnosis is more common than drug errors or wrong-site surgery. … March 7, 2007 The pain of wrong site surgery. … September 29, 2017 The right and wrong way to talk to patients about adverse events.

205. Fatal outcome after inadvertent injection of topical epinephrine. | PSNet
     psnet.ahrq.gov/issue/fatal-outcome-after-inadvertent-injection-topical-epinephrine
     May 07, 2018 - Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong … Site, Wrong Procedure and Wrong Person Surgery.

206. Discrepancy between emergency department admission diagnosis and hospital discharge diagnosis and its impact on length of stay, up-triage to the intensive care unit, and mortality. | PSNet
     psnet.ahrq.gov/issue/discrepancy-between-emergency-department-admission-diagnosis-and-hospital-discharge-diagnosis
     December 08, 2021 - perspective-taking on challenging premature closure after pediatric ICU physicians receive hand-off with the wrong … Related Resources The AHRQ Report on Diagnostic Errors in the Emergency Department: the wrong … answer to the wrong question.

207. From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case | PSNet
     psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premature-closure-and-anchoring-complicated-case
     October 02, 2013 - From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case … From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case. … From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case. … difficult to measure.( 2 ) The relatively long time lag between error and detection (compared with wrong-site … From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case.

208. Differences between methods of detecting medication errors: a secondary analysis of medication administration errors using incident reports, the Global Trigger Tool method, and observations. | PSNet
     psnet.ahrq.gov/issue/differences-between-methods-detecting-medication-errors-secondary-analysis-medication
     December 18, 2019 - For example, incident reports most commonly identified wrong dose and wrong time errors.

209. Application of Safety-II Principles | PSNet
     psnet.ahrq.gov/perspective/application-safety-ii-principles
     August 28, 2024 - patient safety is referred to as Safety-I , which defines safety as a condition where as few things go wrong … But it falls short because it emphasizes the few things that go wrong rather than seeking to understand … Rather than defining safety as the absence of adverse events, where as few things as possible go wrong … Labeling a review as an investigation may imply someone did something wrong. … For example, most people don't fall or get a wrong site surgery.

210. National Center for Patient Safety Falls Toolkit 2004. | PSNet
     psnet.ahrq.gov/issue/national-center-patient-safety-falls-toolkit-2004
     May 24, 2017 - March 14, 2016 Mix-up (wrong route of administration) of bladder irrigation with intravenous … April 6, 2011 Incidence, patterns, and prevention of wrong-site surgery. … &M Cases Too Hot For Comfort December 1, 2007 Mix-up (wrong

211. Tools for Optimizing Medication Safety (TOP-MEDS) | Digital Healthcare Research
     digital.ahrq.gov/ahrq-funded-projects/tools-optimizing-medication-safety-top-meds
     January 01, 2023 - selected and dosed improperly; confusion around the names of medications may cause patients to receive the wrong … × Disclaimer Disclaimer details Close Automated detection of wrong-drug … Automated detection of wrong-drug prescribing errors. … Technology: Electronic Health Record/Electronic Medical Record Indication-based prescribing prevents wrong-patient … Indication-based prescribing prevents wrong-patient medication errors in computerized provider order

212. A biased test kept thousands of Black people from getting a kidney transplant. | PSNet
     psnet.ahrq.gov/issue/biased-test-kept-thousands-black-people-getting-kidney-transplant
     September 02, 2016 - determine eligibility for a kidney transplant and how transplant centers are working to correct that wrong … December 5, 2018 Third wrong-sided brain surgery at R.I. hospital.

213. Improving Communication and Teamwork in the Surgical Environment Module: Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/improving-fac-notes.html
     May 01, 2017 - Operating room briefings and wrong-site surgery. … Use of the briefing card led to a drop in wrong-site surgeries and other adverse events. … Reported problems include wrong-site surgeries, wrong procedures, wrong or missing implants, wrong medications … , unidentified allergies, and/or wrong equipment. … Operating room briefings and wrong-site surgery.

214. Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong. | PSNet
     psnet.ahrq.gov/web-mm/fecal-contamination-peritoneum-laparoscopic-trocar-injury-routine-operation-goes-wrong
     March 03, 2021 - Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong … Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong … Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong … Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong

215. Hardwiring patient blood management: harnessing information technology to optimize transfusion practice. | PSNet
     psnet.ahrq.gov/issue/hardwiring-patient-blood-management-harnessing-information-technology-optimize-transfusion
     September 20, 2012 - September 20, 2023 Electronic patient identification for sample labeling reduces wrong … March 20, 2019 Factors associated with wrong blood in tube errors: an international case … November 17, 2021 Emergency departments are higher-risk locations for wrong blood in

216. Patients' and physicians' attitudes regarding the disclosure of medical errors. | PSNet
     psnet.ahrq.gov/issue/patients-and-physicians-attitudes-regarding-disclosure-medical-errors
     March 21, 2017 - November 23, 2016 When Things Go Wrong: Voices of Patients and Families. … 18, 2016 More than words: patients' views on apology and disclosure when things go wrong … February 16, 2011 When Things Go Wrong: Responding to Adverse Events.

217. 40 of K | PSNet
     psnet.ahrq.gov/web-mm/40-k
     January 12, 2011 - The abbreviation "K" led to administration of the wrong drug. … accurately and efficiently evaluate medication orders for appropriateness.( 9 ) When an order is not clearly wrong … Available studies demonstrate that ADDs might reduce "wrong time" (usually late) medication errors, but … possibly increase risk for more serious wrong drug and wrong dose errors.( 14 ) The ISMP Medication

218. Strategies to Improve Organizational Health Literacy. | PSNet
     psnet.ahrq.gov/primer/strategies-improve-organizational-health-literacy
     August 30, 2023 - adverse events associated with health literacy include mistakes in diabetes management ; 1 taking the wrong … inhalers and aerosol medications; 4  falls; delays in receiving treatment, surgery, or tests ; and wrong … procedure or wrong site surgery. … WebM&M Cases Medication Errors in Retail Pharmacies: Wrong … Patient, Wrong Instructions.

219. Errors in otolaryngology revisited. | PSNet
     psnet.ahrq.gov/issue/errors-otolaryngology-revisited
     August 11, 2010 - For instance, wrong-site surgeries continue to occur despite garnering major attention over the past … RIS Download Citation Related Resources From the Same Author(s) Wrong-site

220. A Prototype Computerized Provider Order Entry System Reduced Medication Errors | Digital Healthcare Research
     digital.ahrq.gov/2018-year-review/research-spotlights/prototype-computerized-provider-order-entry-system-reduced
     January 01, 2018 - Medication errors may also occur during the prescribing process, including prescribing the wrong medication … , wrong dose, or the wrong frequency of taking the medication.