Results

Total Results: 1,736 records

Showing results for "wrong".

221. Summary of Survey Findings | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-culture-survey-brazil-summary.html
     August 01, 2024 - may have missed a diagnosis, and the second related to whether the office was informed when a missed, wrong … When a missed, wrong, or delayed diagnosis happens in this office, we are informed about it.  52.3% 56%

222. Adverse Events, Near Misses, and Errors | PSNet
     psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors
     March 30, 2022 - Errors are defined as "an act of commission (doing something wrong) or omission (failing to do the right … Error : a broader term referring to any act of commission (doing something wrong) or omission (failing … June 1, 2022 View More Related WebM&M “This is the wrong patient's blood … : Evaluating a Near-Miss Wrong Transfusion Event January 29, 2020 Near Miss With Neonate October

223. Pharmacy dispensing of electronically discontinued medications. | PSNet
     psnet.ahrq.gov/issue/pharmacy-dispensing-electronically-discontinued-medications
     October 03, 2012 - June 23, 2009 Ventilator-associated pneumonia—the wrong quality measure for benchmarking … September 22, 2021 View More Related Resources Wrong drug and wrong

224. Effectiveness and efficiency of root cause analysis in medicine. | PSNet
     psnet.ahrq.gov/issue/effectiveness-and-efficiency-root-cause-analysis-medicine
     July 11, 2012 - September 14, 2016 Wrong-site and wrong-patient procedures in the Universal Protocol … October 13, 2010 Wrong-site craniotomy: analysis of 35 cases and systems for prevention

225. Case 34-2010: a 65-year-old woman with an incorrect operation on the left hand. | PSNet
     psnet.ahrq.gov/issue/case-34-2010-65-year-old-woman-incorrect-operation-left-hand
     March 13, 2013 - usual clinical focus, this article discusses a never event —a case of a patient who underwent the wrong … February 23, 2011 The wrong foot, and other tales of surgical error.

226. Importance of Following Safe Practices for Infant Feeding and Handling Expressed Breast Milk | PSNet
     psnet.ahrq.gov/web-mm/importance-following-safe-practices-infant-feeding-and-handling-expressed-breast-milk
     January 31, 2024 - The patient was fed EBM from the wrong mother, which resulted in exposure to potentially infectious breast … In this case, failure to follow unit policy in scanning EBM led to administering EBM from the wrong mother … Improving Safety Standardized Processes for Infant Feeding Expressed breast milk being given to the wrong … type of infant feeding, which is intended to prevent expressed breast milk from being given to the wrong … to patient safety by not only alerting the administering team members if they are administering the wrong

227. Innovations | PSNet
     psnet.ahrq.gov/innovations
     February 26, 2025 - EMERGING INNOVATIONS A standardized marking procedure for ENT operations to prevent wrong-site surgery … March 29, 2023 Although wrong-site surgeries are rare, they can be devastating to … Institutional Reporting (3) Never Events (3) Inpatient Suicide (1) Wrong … A standardized marking procedure for ENT operations to prevent wrong-site surgery: development, establishment … Share Facebook Twitter Linkedin Copy URL Although wrong-site

228. Columbia University | Digital Healthcare Research
     digital.ahrq.gov/organization/columbia-university
     January 01, 2023 - HS023963 Principal Investigator(s) Schnall, Rebecca Assess Risk of Wrong-Patient … Multiple Records Open Description This project compared the risk of orders placed on the wrong

229. Improving-Facnotes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/improving/improving-facnotes.docx
     May 01, 2017 - communication has resulted in serious patient safety events such as teams performing a procedure on the wrong … 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. … These include fears of being embarrassed, feeling stupid, being ridiculed, being yelled at, being wrong

230. ISMP survey on tall man (mixed case) lettering to reduce drug name confusion. | PSNet
     psnet.ahrq.gov/issue/ismp-survey-tall-man-mixed-case-lettering-reduce-drug-name-confusion
     January 26, 2023 - April 25, 2018 Dangerous wrong-route errors with tranexamic acid. … February 18, 2014 Getting the wrong person's medicine at the pharmacy: easy steps consumers

231. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/probabilistic-thinking1.html
     September 01, 2022 - References Errors that occur during the diagnostic process can lead to missed or wrong

232. A descriptive study of morbidity and mortality conferences and their conformity to medical incident analysis models: results of the morbidity and mortality conference improvement study, phase 1. | PSNet
     psnet.ahrq.gov/issue/descriptive-study-morbidity-and-mortality-conferences-and-their-conformity-medical-incident
     September 28, 2010 - July 1, 2016 Achieving the National Quality Forum's "Never Events": prevention of wrong … site, wrong procedure, and wrong patient operations.

233. ISMP Medication Errors Reporting Program. | PSNet
     psnet.ahrq.gov/issue/ismp-medication-errors-reporting-program
     January 26, 2023 - April 25, 2018 Dangerous wrong-route errors with tranexamic acid. … February 18, 2014 Getting the wrong person's medicine at the pharmacy: easy steps consumers

234. Oral Dosage Forms that Should Not Be Crushed. | PSNet
     psnet.ahrq.gov/issue/oral-dosage-forms-should-not-be-crushed
     January 26, 2023 - April 25, 2018 Dangerous wrong-route errors with tranexamic acid. … February 18, 2014 Getting the wrong person's medicine at the pharmacy: easy steps consumers

235. ISMP Survey on IV Push Medication Practices. | PSNet
     psnet.ahrq.gov/issue/ismp-survey-iv-push-medication-practices
     January 26, 2023 - April 25, 2018 Dangerous wrong-route errors with tranexamic acid. … February 18, 2014 Getting the wrong person's medicine at the pharmacy: easy steps consumers

236. Independent double checks: undervalued and misused. | PSNet
     psnet.ahrq.gov/issue/independent-double-checks-undervalued-and-misused
     July 12, 2023 - April 26, 2023 Administering a saline flush "site unseen" can lead to a wrong … February 17, 2015 A crack in our best armor: "wrong patient" injections from insulin

237. Optimize Briefings and Debriefings: Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/surgery/modules/implementation/opt-briefings-fac-notes.html
     December 01, 2017 - Where could things go wrong with this procedure and specifically with this case? … Slide 23: What Is Most Likely To Go Wrong? Ask: What is most likely to go wrong? … Slide 24: What Is Most Likely To Go Wrong? … Slide 25: What Is Most Likely To Go Wrong? … What went wrong, if anything? Were patient identification and specimen name verified?

238. ISMP Medication Safety Self Assessment® for Perioperative Settings. | PSNet
     psnet.ahrq.gov/issue/ismp-medication-safety-self-assessmentr-perioperative-settings
     January 26, 2023 - April 25, 2018 Dangerous wrong-route errors with tranexamic acid. … February 18, 2014 Getting the wrong person's medicine at the pharmacy: easy steps consumers

239. HSIB Maternity Investigation Programme Year in Review 2021/22. Summary of Highlights, Themes and Future Work. | PSNet
     psnet.ahrq.gov/issue/hsib-maternity-investigation-programme-year-review-202122-summary-highlights-themes-and
     September 14, 2022 - February 16, 2022 Wrong Site Surgery–Wrong Tooth Extraction.

240. My patient almost died from a mistake I made. I apologized and it changed my life. | PSNet
     psnet.ahrq.gov/issue/my-patient-almost-died-mistake-i-made-i-apologized-and-it-changed-my-life
     October 23, 2019 - September 11, 2019 Your diagnosis was wrong. … August 24, 2011 Hospital tells of surgery on wrong side.