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Showing results for "wrong".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44104/psn-pdf
    July 16, 2015 - Errors upstream and downstream to the Universal Protocol associated with wrong surgery events in the … Errors upstream and downstream to the Universal Protocol associated with wrong surgery events in the … https://psnet.ahrq.gov/primer/root-cause-analysis 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 … /issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery

  2. Patient safety in North America: beyond "operate through your initials" and "sign your site." | PSNet

    psnet.ahrq.gov/issue/patient-safety-north-america-beyond-operate-through-your-initials-and-sign-your-site
    March 18, 2009 - The authors discuss the state of patient safety, wrong-site surgery , and future areas for improvement … November 16, 2016 Wrong-site orthopedic operations on the extremities: the Pennsylvania … 2012 Assessment of the implementation of a national patient safety alert to reduce wrong … March 18, 2009 Most surgery in wrong spot done on spine: 11 such cases found in state … August 13, 2008 The prevalence of wrong level surgery among spine surgeons.

  3. Surgical site signing and "time out": issues of compliance or complacence. | PSNet

    psnet.ahrq.gov/issue/surgical-site-signing-and-time-out-issues-compliance-or-complacence
    January 07, 2011 - Adherence to measures to prevent wrong-site surgery remained lower than optimal over a 2-year period … January 17, 2019 Wrong-site orthopedic operations on the extremities: the Pennsylvania … March 3, 2011 Operating room briefings and wrong-site surgery. … June 24, 2009 Most surgery in wrong spot done on spine: 11 such cases found in state … August 13, 2008 Incidence, patterns, and prevention of wrong-site surgery.

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867388/psn-pdf
    December 18, 2024 - Secure messaging use and wrong-patient ordering errors among inpatient clinicians. … Secure messaging use and wrong-patient ordering errors among inpatient clinicians. … https://psnet.ahrq.gov/issue/secure-messaging-use-and-wrong-patient-ordering-errors-among-inpatient- … https://psnet.ahrq.gov/issue/secure-messaging-use-and-wrong-patient-ordering-errors-among-inpatient-clinicians … https://psnet.ahrq.gov/issue/secure-messaging-use-and-wrong-patient-ordering-errors-among-inpatient-clinicians

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39404/psn-pdf
    March 31, 2010 - Incidence and root cause analysis of wrong-site pain management procedures: a multicenter study. … multicenter-study Wrong-site surgeries are considered rare but devastating never events. … A wrong-site surgery near miss is discussed in this AHRQ WebM&M commentary. … incorrect-surgical-procedures-within-and-outside-operating-room https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery … https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44248/psn-pdf
    May 26, 2016 - Wrong-site surgery, retained surgical items, and surgical fires: a systematic review of surgical never … Wrong-Site Surgery, Retained Surgical Items, and Surgical Fires : A Systematic Review of Surgical Never … https://psnet.ahrq.gov/primer/never-events https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery … https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery … psnet.ahrq.gov/issue/risk-factors-retained-instruments-and-sponges-after-surgery https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44020/psn-pdf
    March 25, 2015 - Wrong-site orthopedic operations on the extremities: the Pennsylvania experience. … https://psnet.ahrq.gov/issue/wrong-site-orthopedic-operations-extremities-pennsylvania-experience Wrong-site … ://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery https://psnet.ahrq.gov/ … https://psnet.ahrq.gov/issue/use-anatomic-marking-form-alternative-universal-protocol-preventing-wrong-site-wrong … https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery

  8. Surgical site verification: A through Z. | PSNet

    psnet.ahrq.gov/issue/surgical-site-verification-through-z
    October 26, 2022 - January 17, 2019 Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong … Site, Wrong Procedure and Wrong Person Surgery. … February 9, 2011 Operating room briefings and wrong-site surgery. … July 28, 2010 Doing the "right" things to correct wrong-site surgery. … July 10, 2008 'Wrong site' surgeries on the rise.

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39546/psn-pdf
    May 26, 2010 - Avoiding wrong site surgery: a systematic review. … Avoiding wrong site surgery: a systematic review. … proposes specific interventions to prevent wrong-site spinal surgery. … /wrong-site-wrong-procedure-and-wrong-patient-surgery https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery … https://psnet.ahrq.gov/issue/prevalence-wrong-level-surgery-among-spine-surgeons

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43867/psn-pdf
    March 11, 2015 - Applying fault tree analysis to the prevention of wrong- site surgery. … Applying fault tree analysis to the prevention of wrong-site surgery. … https://psnet.ahrq.gov/issue/applying-fault-tree-analysis-prevention-wrong-site-surgery This systematic … /issue/incidence-patterns-and-prevention-wrong-site-surgery 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

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852751/psn-pdf
    August 23, 2023 - Automated search methods for identifying wrong patient order entry-a scoping review. … Automated search methods for identifying wrong patient order entry—a scoping review. … https://psnet.ahrq.gov/issue/automated-search-methods-identifying-wrong-patient-order-entry-scoping- … review Understanding causes of wrong-patient order entry (WPOE) can help develop interventions to reduce … https://psnet.ahrq.gov/issue/automated-search-methods-identifying-wrong-patient-order-entry-scoping-review

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41245/psn-pdf
    March 29, 2012 - The occurrence of wrong-site surgery self-reported by candidates for certification by the American Board … The occurrence of wrong-site surgery self-reported by candidates for certification by the American Board … The most common errors reported were related to wrong-level spine surgery. … https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery https://psnet.ahrq.gov … ://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46178/psn-pdf
    December 22, 2017 - Evaluating serial strategies for preventing wrong-patient orders in the NICU. … Evaluating Serial Strategies for Preventing Wrong-Patient Orders in the NICU. … https://psnet.ahrq.gov/issue/evaluating-serial-strategies-preventing-wrong-patient-orders-nicu Wrong-patient … A previous WebM&M commentary highlights a case of wrong- patient identification. … //psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40013/psn-pdf
    July 24, 2011 - Patient participation in surgical site marking: can this be an additional tool to help avoid wrong-site … Patient participation in surgical site marking: can this be an additional tool to help avoid wrong-site … https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery https://psnet.ahrq.gov … /issue/wrong-site-and-wrong-patient-procedures-universal-protocol-era-analysis-prospective-database https … ://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery

  15. Diagnostic Error Measures: For Quality Improvement & Patient Safety Research (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/adelman-summit2016.pdf
    January 01, 2016 - Wrong Patient Errors Leading to Diagnostic Errors: 1) Order tests on wrong-patient 2) Read results of … wrong-patient 3) Communicate information to the wrong patient. … Wrong Patient Errors Leading to Diagnostic Errors xxVoluntary Reporting Chart Reviews Trigger … JAMA. 2001;285:2114-2120 Wrong-Patient Error Measures Retract-and-Reorder Tool Applied to Complete … on the wrong patient – 1 of 37 admitted patients had an order placed for them that was intended for

  16. Final Progress Report: Safety Advancement in the Emergency Department (pdf file)

    www.ahrq.gov/sites/default/files/2024-01/hall2-report.pdf
    January 01, 2024 - lab(s) ordered Delay or failure to order Wrong study ordered Delay or failure to order Wrong drug … ordered Wrong dose ordered Wrong route ordered Ordered for wrong patient Ordered for wrong time … study performed Study performed on wrong patient Technical errors Wrong drug dispensed Wrong dose … dispensed Wrong route form dispensed Dispensed for wrong patient Delayed or dispensed at wrong time … drug administered Wrong dose administered Administered by wrong route Administered to wrong patient

  17. Using performance improvement to enhance time-out compliance and prevent wrong-site surgery. | PSNet

    psnet.ahrq.gov/issue/using-performance-improvement-enhance-time-out-compliance-and-prevent-wrong-site-surgery
    October 06, 2021 - Commentary Using performance improvement to enhance time-out compliance and prevent wrong-site … Using performance improvement to enhance time-out compliance and prevent wrong-site surgery. … Using performance improvement to enhance time-out compliance and prevent wrong-site surgery. … Prevention February 26, 2025 Patient Safety Primers Wrong-Site … , Wrong-Procedure, and Wrong-Patient Surgery December 15, 2024 Fire safety

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43593/psn-pdf
    May 06, 2015 - Reducing the Risks of Wrong-Site Surgery: Safety Practices from The Joint Commission Center for Transforming … - transforming Wrong-site surgery is a never event, but still occurs at alarming rates. … Charles Vincent discussed a case of a wrong-site procedure. … https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery https://psnet.ahrq.gov … /primer/never-events https://psnet.ahrq.gov/issue/wrong-body-part-wrong-patient-surgeries-continue-despite-new-procedures

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44243/psn-pdf
    November 09, 2015 - Concept analysis: wrong-site surgery. November 9, 2015 Watson DS. … Concept analysis: wrong-site surgery. AORN J. 2015;101(6):650-6. doi:10.1016/j.aorn.2015.03.012. … wrong-site surgeries, they continue to occur. … https://psnet.ahrq.gov/issue/concept-analysis-wrong-site-surgery 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

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35270/psn-pdf
    June 29, 2009 - Potentially inappropriate prescribing in elderly veterans: are we using the wrong drug, wrong dose, … or wrong duration? … Potentially Inappropriate Prescribing in Elderly Veterans: Are We Using the Wrong Drug, Wrong Dose, … or Wrong Duration? … https://psnet.ahrq.gov/issue/potentially-inappropriate-prescribing-elderly-veterans-are-we-using-wrong-drug-wrong-dose-or
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