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Showing results for "wrong".

  1. Automated Retract-and-Reorder Measures to Improve Medication Safety | Digital Healthcare Research

    digital.ahrq.gov/program-overview/research-stories/automated-retract-and-reorder-measures-improve-medication-safety
    January 01, 2023 - (RAR) Measure to identify wrong-patient electronic orders. … The Wrong-Patient RAR measure enabled systematic and objective identification of wrong-patient orders … These measures identify electronic order errors including wrong dosage, wrong route, wrong frequency, … or wrong medication. … Are there differences in frequency by type of errors, for example, wrong-patient versus wrong-dose errors

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36315/psn-pdf
    July 10, 2008 - Wrong-side/wrong-site, wrong-procedure, and wrong- patient adverse events: are they preventable? … Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: Are they preventable? … https://psnet.ahrq.gov/issue/wrong-sidewrong-site-wrong-procedure-and-wrong-patient-adverse-events- … are-they-preventable Although instances of wrong-site, wrong-procedure, and wrong-patient adverse events … https://psnet.ahrq.gov/issue/wrong-sidewrong-site-wrong-procedure-and-wrong-patient-adverse-events-are-they-preventable

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73883/psn-pdf
    September 29, 2021 - Emergency departments are higher-risk locations for wrong blood in tube errors. … risk locations for wrong blood in tube errors. … https://psnet.ahrq.gov/issue/emergency-departments-are-higher-risk-locations-wrong-blood-tube-errors … This study compared wrong blood in tube (WBIT) errors in 9 countries across three settings: emergency … https://psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event https

  4. PowerPoint Presentation (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.341_slideshow.ppt
    March 01, 2015 - on preventing wrong-site surgery Relate the key contributing factors to wrong-site surgery Discuss the … Surgery The Joint Commission defines wrong-site surgery as Any surgery performed on the wrong site … Any procedure performed on the wrong patient Performance of the wrong procedure Wrong-site surgery is … Wrong-patient surgery Wrong-side surgery Wrong-level exposure 7 Facts about the Universal Protocol … Site, Wrong Procedure, Wrong Person Surgery.

  5. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-01/final_spotlight_near_miss_transfusion_01082020_tocme.pdf
    January 01, 2020 - Spotlight Spotlight “This is the wrong patient’s blood!” … Evaluating a Near-Miss Wrong Transfusion Event 4 Case: “This is the wrong patient’s blood” A 74 … Case: “This is the wrong patient’s blood” (3) “THIS IS THE WRONG PATIENT’S BLOOD!” … Case: “This is the wrong patient’s blood” Slide Number 6 Case: “This is the wrong patient’s blood” … (3) “this is the wrong patient’s blood!”

  6. Develop and Validate Health IT Safety Measures to Capture Violations of the 5 Rights of Medication Safety – Final Report (pdf file)

    digital.ahrq.gov/sites/default/files/docs/citation/r01hs024538-adelman-final-report-2022.pdf
    January 01, 2022 - , wrong-medication, wrong-route, and wrong-frequency electronic orders, and describe the frequency in … - Reorder measure can be applied to detect wrong-dose, wrong-medication, wrong-route, wrong-frequency … Dose 20,153 23.6 369.0 Wrong Frequency 12,353 14.4 226.2 Wrong Route 5,556 6.5 101.7 Wrong PRN 1,626 … ), Wrong-Dose Pediatrics (age ≤21 years), Wrong-Frequency, Wrong-PRN, and Wrong-Route RAR measures. … near-miss order errors to develop and validate Wrong-Dose, Wrong-Frequency, Wrong-PRN, and Wrong- Route

  7. Assessment of incorrect surgical procedures within and outside the operating room. A follow-up study from US Veterans Health Administration medical centers. | PSNet

    psnet.ahrq.gov/issue/assessment-incorrect-surgical-procedures-within-and-outside-operating-room-follow-study-us
    October 24, 2018 - The Joint Commission and National Quality Forum both consider wrong-site, wrong-procedure, and wrong-patient … A WebM&M commentary examined an incident involving a wrong-side surgery. … April 30, 2014 Prevention of wrong-site tooth extraction: clinical guidelines. … September 20, 2011 Operating room briefings and wrong-site surgery. … July 28, 2010 Incidence and root cause analysis of wrong-site pain management procedures

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47922/psn-pdf
    May 29, 2019 - Effect of restriction of the number of concurrently open records in an electronic health record on wrong-patient … Effect of Restriction of the Number of Concurrently Open Records in an Electronic Health Record on Wrong-Patient … psnet.ahrq.gov/issue/effect-restriction-number-concurrently-open-records-electronic-health-record- wrong-patient … Having multiple patient records open in the electronic health record increases the potential risk of wrong … the 3356 clinicians with nearly 4.5 million order sessions, there were no significant differences in wrong

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36833/psn-pdf
    March 03, 2011 - Achieving the National Quality Forum's "Never Events": prevention of wrong site, wrong procedure, and … wrong patient operations. … Achieving the National Quality Forum's "Never Events": prevention of wrong site, wrong procedure, and … wrong patient operations. … /issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery https://psnet.ahrq.gov

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867392/psn-pdf
    December 18, 2024 - issue/large-scale-observational-study-ai-based-patient-and-surgical-material- verification-system Wrong-side … and wrong-patient surgical errors can have devastating consequences. … large-scale-observational-study-ai-based-patient-and-surgical-material-verification-system https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery … https://psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side https://psnet.ahrq.gov

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49726/psn-pdf
    March 01, 2015 - wrong patient. … Wrong-side surgery is a surgical procedure that involves operating on the wrong extremity or wrong side … Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. … Often used as a general term for wrong level or part, wrong patient, and wrong side surgery. … Wrong Side A surgical procedure that involves operating on the wrong extremity or wrong side of the

  12. Eight-year experience with a neurosurgical checklist. | PSNet

    psnet.ahrq.gov/issue/eight-year-experience-neurosurgical-checklist
    September 27, 2023 - The institution did not experience any wrong-site surgeries during that time. … December 22, 2010 Wrong-site craniotomy: analysis of 35 cases and systems for prevention … September 15, 2010 Wrong-site sinus surgery in otolaryngology. … July 23, 2010 Avoiding wrong site surgery: a systematic review. … May 26, 2010 Third wrong-sided brain surgery at R.I. hospital.

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866441/psn-pdf
    August 07, 2024 - associated with a 40% reduction in the odds of retract-and-reorder events, a surrogate measure of wrong-patient … association-patient-photographs-and-reduced-retract-and-reorder-events https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery … one-dose-two-errors https://psnet.ahrq.gov/issue/association-display-patient-photographs-electronic-health-record-wrong-patient-order-entry … https://psnet.ahrq.gov/issue/automated-search-methods-identifying-wrong-patient-order-entry-scoping-review

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60941/psn-pdf
    September 23, 2020 - Wrong-patient ordering errors in peripartum mother- newborn pairs: a unique patient-safety challenge … Wrong-patient ordering errors in peripartum mother-newborn pairs: a unique patient-safety challenge … https://psnet.ahrq.gov/issue/wrong-patient-ordering-errors-peripartum-mother-newborn-pairs-unique- patient-safety-challenge … This commentary presents two cases of near-miss wrong-patient order errors between mother-newborn … https://psnet.ahrq.gov/issue/wrong-patient-ordering-errors-peripartum-mother-newborn-pairs-unique-patient-safety-challenge

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39948/psn-pdf
    December 21, 2014 - Wrong-site and wrong-patient procedures in the Universal Protocol era: analysis of a prospective database … Wrong-site and wrong-patient procedures in the universal protocol era: analysis of a prospective database … https://psnet.ahrq.gov/issue/wrong-site-and-wrong-patient-procedures-universal-protocol-era-analysis- … prospective-database Efforts to prevent wrong-site and wrong-patient surgical errors (WSPEs) initially … https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery https://psnet.ahrq.gov

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46274/psn-pdf
    September 13, 2017 - Wrong-site surgery in California, 2007–2014. … This study found that between 2007 and 2014, there were 95 cases involving wrong-site surgeries, wrong-site … procedures, wrong procedures, and procedures performed on the wrong patient reported to the California … https://psnet.ahrq.gov/issue/wrong-site-surgery-california-2007-2014 https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery … https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery https://psnet.ahrq.gov

  17. Incorrect surgical procedures within and outside of the operating room: a follow-up report. | PSNet

    psnet.ahrq.gov/issue/incorrect-surgical-procedures-within-and-outside-operating-room-follow-report
    April 30, 2014 - procedures in the Veterans Affairs (VA) system found an overall decline in the number of reported wrong-site … , wrong-patient, and wrong-procedure errors compared with the authors' prior study . … April 30, 2014 Preventing wrong site, procedure, and patient events using a common cause … January 4, 2012 Application of human error theory in case analysis of wrong procedures … Site, Wrong Procedure and Wrong Person Surgery.

  18. Incorrect surgical procedures within and outside of the operating room. | PSNet

    psnet.ahrq.gov/issue/incorrect-surgical-procedures-within-and-outside-operating-room
    November 21, 2011 - Wrong-patient and wrong-site surgeries are considered never events , as they are devastating errors … December 21, 2014 Preventing wrong site, procedure, and patient events using a common … Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong … Site, Wrong Procedure and Wrong Person Surgery. … November 18, 2009 Wrong site surgery near misses and actual occurrences.

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40520/psn-pdf
    June 08, 2011 - Wrong body part, wrong patient surgeries continue despite new procedures. … https://psnet.ahrq.gov/issue/wrong-body-part-wrong-patient-surgeries-continue-despite-new-procedures … https://psnet.ahrq.gov/issue/wrong-body-part-wrong-patient-surgeries-continue-despite-new-procedures … https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery https://psnet.ahrq.gov … /issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41835/psn-pdf
    May 19, 2015 - Interventions for reducing wrong-site surgery and invasive procedures. … https://psnet.ahrq.gov/issue/interventions-reducing-wrong-site-surgery-and-invasive-procedures Wrong-site … , wrong-patient, or wrong-procedure errors. … //psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery https://psnet.ahrq.gov/primer … /never-events https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery
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