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Total Results: 1,736 records

Showing results for "wrong".

381. Preventing-Cauti-Icu-Setting-Module 2-Speaker-Notes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/cauti-tools/cauti-icu/preventing-cauti-icu-setting-module_2-speaker-notes.docx
     September 01, 2015 - Transporter: “Did I do something wrong?” Nurse: “Not exactly. … In this scenario, the transporter didn’t understand what might happen because of wrong bag placement

382. Retained surgical items: a problem yet to be solved. | PSNet
     psnet.ahrq.gov/issue/retained-surgical-items-problem-yet-be-solved
     September 24, 2014 - April 22, 2020 Wrong-site surgery, retained surgical items, and surgical fires: a systematic … 2013 Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site

383. Moving beyond the weekend effect: how can we best target interventions to improve patient care? | PSNet
     psnet.ahrq.gov/issue/moving-beyond-weekend-effect-how-can-we-best-target-interventions-improve-patient-care
     September 09, 2015 - 30, 2023 The AHRQ Report on Diagnostic Errors in the Emergency Department: the wrong … answer to the wrong question.

384. Anticoagulant medication errors in nursing homes: characteristics, causes, outcomes, and association with patient harm. | PSNet
     psnet.ahrq.gov/issue/anticoagulant-medication-errors-nursing-homes-characteristics-causes-outcomes-and-association
     December 15, 2011 - September 23, 2020 The AHRQ Report on Diagnostic Errors in the Emergency Department: the wrong … answer to the wrong question.

385. A qualitative evaluation of the barriers and facilitators toward implementation of the WHO surgical safety checklist across hospitals in England: lessons from the "Surgical Checklist Implementation Project." | PSNet
     psnet.ahrq.gov/issue/qualitative-evaluation-barriers-and-facilitators-toward-implementation-who-surgical-safety
     January 19, 2016 - June 22, 2016 Compliance with a time-out procedure intended to prevent wrong surgery … July 24, 2013 Information needs in operating room teams: what is right, what is wrong

386. Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients. | PSNet
     psnet.ahrq.gov/issue/root-cause-analysis-reports-help-identify-common-factors-delayed-diagnosis-and-treatment
     October 24, 2018 - October 24, 2018 Errors upstream and downstream to the Universal Protocol associated with wrong … April 25, 2016 Wrong-side thoracentesis: lessons learned from root cause analysis.

387. The Lost Start Date: an Unknown Risk of E-prescribing | PSNet
     psnet.ahrq.gov/web-mm/lost-start-date-unknown-risk-e-prescribing
     December 02, 2020 - various components of this system require a situational awareness of the various things that can go wrong … ) Association of display of patient photographs in the electronic health record with wrong-patient … Effect of restriction of the number of concurrently open records in an electronic health record on wrong-patient … WebM&M Cases Multiple Levels Involved in Prescribing the Wrong … June 16, 2019 WebM&M Cases Bad Writing, Wrong Medication

388. Cups of Error | PSNet
     psnet.ahrq.gov/web-mm/cups-error
     January 12, 2011 - When the time came to administer the medication(s), the student in this case picked up the wrong cup … different student expecting to give the above medications reviewed the ones in her cup and discovered the wrong … students conclude any suspicions they might have about the accuracy of statements and actions must be wrong

389. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33605/psn-pdf
     March 12, 2021 - variability, dose preparation is uniquely challenging in pediatric populations, which increases risk for wrong … Wrong dose, missing doses, and wrong medication are the most commonly reported administration errors … To help mitigate of wrong dose errors, warfarin tablet colors are standardized by their strength across

390. Technology as a Tool for Improving Patient Safety | PSNet
     psnet.ahrq.gov/perspective/technology-tool-improving-patient-safety
     April 26, 2023 - Medication Safety Measure Development project, aims to develop and validate measure specifications for wrong-patient … , wrong-dose, wrong-medication, wrong-route, and wrong-frequency medication orders within EHR systems

391. A national survey assessing the number of records allowed open in electronic health records at hospitals and ambulatory sites. | Digital Healthcare Research
     digital.ahrq.gov/ahrq-funded-projects/assess-risk-wrong-patient-errors-emr-allows-multiple-records-open/citation/survey
     January 01, 2023 - 28419267 Principal Investigator Adelman, Jason Stuart Project Name Assess Risk of Wrong-Patient

392. Radiation Safety | PSNet
     psnet.ahrq.gov/primer/radiation-safety
     September 15, 2024 - harm patients generally involve overexposure to radiation, which can cause direct toxicity; cases of wrong-patient … and wrong-site errors have also been reported. … 2010 news investigation found that many cases in which patients experienced serious harm were due to wrong

393. High Reliability Organization (HRO) Principles and Patient Safety | PSNet
     psnet.ahrq.gov/perspective/high-reliability-organization-hro-principles-and-patient-safety
     February 26, 2025 - orientation can help is by helping people be systematic and intentional about things that have gone wrong … of the system,” we invite ourselves to think more intentionally and anticipate things that might go wrong … And then, when things do go wrong, how do we put a process in place to adapt and contain them? … Let us talk about what went wrong. Who did not get listened to in our team?” … Are we making sure we are thinking preemptively about what could go wrong?

394. In Conversation with Timothy Vogus about High Reliability Organization (HRO) Principles and Patient Safety | PSNet
     psnet.ahrq.gov/perspective/conversation-timothy-vogus-about-high-reliability-organization-hro-principles-and
     February 26, 2025 - orientation can help is by helping people be systematic and intentional about things that have gone wrong … of the system,” we invite ourselves to think more intentionally and anticipate things that might go wrong … And then, when things do go wrong, how do we put a process in place to adapt and contain them? … Let us talk about what went wrong. Who did not get listened to in our team?” … Are we making sure we are thinking preemptively about what could go wrong?

395. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867757/psn-pdf
     March 12, 2025 - medication-administration-errors https://psnet.ahrq.gov/perspective/medication-safety-nursing-homes-whats-wrong-and-how-fix-it

396. The Different Count Contributions to Retention (pdf file)
     psnet.ahrq.gov/sites/default/files/2024-10/The%20Different%20Count%20Contributions%20to%20Retention.pdf
     January 01, 2024 - Types of events which required reporting included, medication errors, wrong surgery cases, child abduction … A frequent finding in the retained sponge cases was that the final sponge count was wrong. … To understand why the sponge counts were wrong requires a deeper analysis of the policies and practices … identified, nursing communication strategies are employed to inform the surgeon that something is wrong

397. Effect of restricting electronic health records on clinician efficiency: Substudy of a randomized clinical trial. | Digital Healthcare Research
     digital.ahrq.gov/ahrq-funded-projects/assess-risk-wrong-patient-errors-emr-allows-multiple-records-open/citation/effect
     January 01, 2023 - 37011638/ Principal Investigator Adelman, Jason Stuart Project Name Assess Risk of Wrong-Patient

398. Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff. | PSNet
     psnet.ahrq.gov/issue/personal-protective-equipment-preventing-highly-infectious-diseases-due-exposure-contaminated
     April 23, 2014 - February 15, 2023 The AHRQ Report on Diagnostic Errors in the Emergency Department: the wrong … answer to the wrong question.

399. Kaushal R et al. 2003 "Effects of computerized physician order entry and clinical decision support systems on medication safety - a systematic review." | Digital Healthcare Research
     digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/kaushal-r-et-al-2003
     January 01, 2003 - "Finally, physicians can electronically write an order in the wrong patient's record, analogous to handwriting … an order in the wrong patient's medical chart."

400. Final Progress Report: Automated Image Analysis for the Prevention of Radiotherapy Delivery Errors (pdf file)
     www.ahrq.gov/sites/default/files/2024-11/lamb-report.pdf
     January 01, 2024 - image guided radiotherapy, which would allow detection and prevention of delivery of radiation to the wrong … error leads to so-called never events: treatments with serious alignment errors 2 or with the wrong … interlock the radiotherapy machine to prevent treatment if the patient is not correctly aligned or if the wrong … Results have been obtained from 2018-2020 and indicate 2 unreported near-miss wrong-patient treatments