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Showing results for "wrong".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37500/psn-pdf
    January 30, 2008 - The prevalence of wrong level surgery among spine surgeons. … The prevalence of wrong level surgery among spine surgeons. … https://psnet.ahrq.gov/issue/prevalence-wrong-level-surgery-among-spine-surgeons This study surveyed … more than 400 neurosurgeons and found that 50% reported performing a wrong level surgery at least once … /issue/incidence-patterns-and-prevention-wrong-site-surgery

  2. Transfusion safety: the nature and outcomes of errors in patient registration. | PSNet

    psnet.ahrq.gov/issue/transfusion-safety-nature-and-outcomes-errors-patient-registration
    December 16, 2020 - July 21, 2021 Understanding and preventing wrong-patient electronic orders: a randomized … May 10, 2023 Adding automation and independent dual verification to reduce wrong blood … June 29, 2022 Factors associated with wrong blood in tube errors: an international case … : Evaluating a Near-Miss Wrong Transfusion Event January 29, 2020 The wicked … June 14, 2019 Electronic patient identification for sample labeling reduces wrong blood

  3. Never Events Analysis of HSIB's National Investigations Report. | PSNet

    psnet.ahrq.gov/issue/never-events-analysis-hsibs-national-investigations-report
    June 09, 2021 - nbsp;  Copy Citation Related Resources From the Same Author(s) Wrong … Site Surgery–Wrong Tooth Extraction. … June 9, 2021 Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient Settings … Improving Diagnostic Safety and Quality April 26, 2023 Wrong … Site Surgery - Wrong Patient: Invasive Procedures in Outpatient Settings.

  4. Providing Evidence and Developing a Toolkit to Accelerate the Adoption of Patient Photographs in Electronic Health Records - Final Report (pdf file)

    digital.ahrq.gov/sites/default/files/docs/citation/r01hs024713-adelman-final-report-2023.pdf
    January 01, 2023 - Background The problem of wrong-patient orders. … ID Verification Alerts to prevent wrong-patient orders. … alerts significantly reduced wrong-patient orders. … Wrong-Patient Retract-and-Reorder Measure for identifying wrong-patient errors. … 1 wrong-patient order.

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60565/psn-pdf
    June 03, 2020 - But hospitals got some things wrong. June 3, 2020 Ofri D. The public has been forgiving. … But hospitals got some things wrong. New York Times. 2020; May 21. … https://psnet.ahrq.gov/issue/public-has-been-forgiving-hospitals-got-some-things-wrong The complexity … https://psnet.ahrq.gov/issue/public-has-been-forgiving-hospitals-got-some-things-wrong https://psnet.ahrq.gov

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40707/psn-pdf
    March 11, 2013 - More than words: patients' views on apology and disclosure when things go wrong in cancer care. … More than words: patients' views on apology and disclosure when things go wrong in cancer care. … https://psnet.ahrq.gov/issue/more-words-patients-views-apology-and-disclosure-when-things-go-wrong- … efforts have included implementation of formal disclosure policies, such as Harvard’s When Things Go Wrong … https://psnet.ahrq.gov/issue/more-words-patients-views-apology-and-disclosure-when-things-go-wrong-cancer-care

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36604/psn-pdf
    June 04, 2024 - Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site … issue/national-quality-forum https://psnet.ahrq.gov/primer/never-events https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery

  8. Leveraging Health IT to Test Solutions That Are Replicable, Scalable, and Improve Patient Safety | Digital Healthcare Research

    digital.ahrq.gov/2018-year-review/research-spotlights/leveraging-health-it-test-solutions-are-replicable-scalable-and
    January 01, 2018 - Wachter, Murray, and Adler-Milstein 4 Wrong-patient errors can affect any patient in any healthcare … Retract-and-Reorder (RAR) Measure that he developed to evaluate the frequency of wrong-patient errors … Having multiple EHRs open simultaneously does not increase wrong-patient orders. … “Placing orders on the wrong patient should never happen. … While no differences in wrong-patient orders were observed between those clinician groups, there was

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43393/psn-pdf
    July 30, 2014 - analyzes the evidence for surgical checklist implementation to determine its usefulness in preventing wrong-site … effectiveness-surgical-safety-checklist-correcting-errors-literature-review-applying-reasons https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery … issue/surgical-checklists-systematic-review-impacts-and-implementation https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36430/psn-pdf
    March 28, 2011 - Experience of wrong site surgery and surgical marking practices among clinicians in the UK. … Experience of wrong site surgery and surgical marking practices among clinicians in the UK. … https://psnet.ahrq.gov/issue/experience-wrong-site-surgery-and-surgical-marking-practices-among- clinicians-uk … The investigators analyzed incidents of wrong-site surgery and surgical marking practices in the United … https://psnet.ahrq.gov/issue/experience-wrong-site-surgery-and-surgical-marking-practices-among-clinicians-uk

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49419/psn-pdf
    October 01, 2003 - Understand the key components of the Universal Protocol for eliminating wrong site, wrong procedure, … wrong person surgery. … Recently, JCAHO released a Universal Protocol for preventing wrong person, wrong procedure, and wrong … Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. [ go to related … Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. [ go to related

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49650/psn-pdf
    March 01, 2012 - The patient returned to his referring physician, who immediately realized that the wrong lesion (the … surgery as any surgery performed on the wrong site or the wrong patient, or performance of the wrong … The patient in this case self-identified the wrong surgical site. … A follow-up review of wrong site surgery. Sentinel Event Alert. December 5, 2001. … Outcome of 6 years of protocol use for preventing wrong site office surgery.

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46688/psn-pdf
    January 01, 2018 - New solutions to reduce wrong route medication errors. … New solutions to reduce wrong route medication errors. … https://psnet.ahrq.gov/issue/new-solutions-reduce-wrong-route-medication-errors Tubing misconnections … This commentary discusses design strategies that can address wrong route medication administration, … https://psnet.ahrq.gov/issue/new-solutions-reduce-wrong-route-medication-errors https://psnet.ahrq.gov

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40377/psn-pdf
    April 20, 2011 - lessons-learned-use-event-reporting-nurses-improve-patient-safety-and-quality 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

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40020/psn-pdf
    September 20, 2011 - the usual clinical focus, this article discusses a never event—a case of a patient who underwent the wrong … year-old-woman-incorrect-operation-left-hand https://psnet.ahrq.gov/primer/never-events https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery … language-proficiency-and-adverse-events-us-hospitals-pilot-study https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37059/psn-pdf
    September 30, 2011 - Preventable errors in the operating room--part 2: retained foreign objects, sharps injuries, and wrong … Preventable errors in the operating room--part 2: retained foreign objects, sharps injuries, and wrong … psnet.ahrq.gov/issue/preventable-errors-operating-room-part-2-retained-foreign-objects-sharps- injuries-and-wrong … Building on part one of this two-part series, the authors discuss wrong-site surgeries and needle stick … psnet.ahrq.gov/issue/preventable-errors-operating-room-part-2-retained-foreign-objects-sharps-injuries-and-wrong

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851656/psn-pdf
    July 26, 2023 - adverse events were improperly functioning equipment (e.g., broken scopes or smoking light cords), wrong … /preventable-mortality-after-common-urological-surgery-failing-rescue https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/858165/psn-pdf
    December 13, 2023 - When public health goes wrong: toward a new concept of public health error. … When public health goes wrong: toward a new concept of public health error. … https://psnet.ahrq.gov/issue/when-public-health-goes-wrong-toward-new-concept-public-health-error Public … https://psnet.ahrq.gov/issue/when-public-health-goes-wrong-toward-new-concept-public-health-error https

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46811/psn-pdf
    May 17, 2018 - psnet.ahrq.gov/issue/surgical-procedure-grid-safety-and-operating-room-communication-multisite- surgery Wrong-patient … and wrong-site surgeries are considered never events. … authors envision the tool to enhance team communication and preparation, which should reduce risk of wrong-site … surgical-procedure-grid-safety-and-operating-room-communication-multisite-surgery https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery

  20. An Etiology for Medication Ordering Errors in CPOE Systems - Final Report (pdf file)

    digital.ahrq.gov/sites/default/files/docs/citation/r21hs025443-abraham-final-report-2020.pdf
    January 01, 2020 - patient, wrong drug). … Wrong Drug An order indicating the wrong medication for the patient. … (7%, n=64), wrong drug (7%, n=56), wrong encounter (1%, n=11), or other (<1%, n=5). … Drug 56 (6.6%) Wrong Encounter 11 (1.3%) Wrong Patient 94 (11.1%) Wrong Route/Dose/Strength 189 ( … type of errors, while cognitive factors predominantly contributed to wrong drug, wrong patient and wrong
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