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Showing results for "wrong".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37343/psn-pdf
    December 02, 2008 - The most common adverse events included wrong lens implants and wrong eye operations, and the authors … /issue/surgical-confusions-ophthalmology https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38708/psn-pdf
    April 30, 2014 - Frequency and clinical importance of pages sent to the wrong physician. … Frequency and clinical importance of pages sent to the wrong physician. … https://psnet.ahrq.gov/issue/frequency-and-clinical-importance-pages-sent-wrong-physician Communication … This study discovered that 14% of text pages were sent to the wrong physician, with nearly 50% of them … https://psnet.ahrq.gov/issue/frequency-and-clinical-importance-pages-sent-wrong-physician https://psnet.ahrq.gov

  3. Right? Left? Neither! | PSNet

    psnet.ahrq.gov/web-mm/right-left-neither
    November 16, 2022 - Neither should operating on the wrong side of the right patient. … JCAHO has recommended a series of steps to prevent wrong-site, wrong-side, and wrong-person procedures … To strengthen defenses against wrong-site and wrong-patient invasive procedures, hospitals should implement … Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. … January 23, 2019 The wrong patient.

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40636/psn-pdf
    November 21, 2011 - 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. … incorrect-surgical-procedures-within-and-outside-operating-room-follow-report https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39595/psn-pdf
    June 15, 2011 - Application of human error theory in case analysis of wrong procedures. June 15, 2011 Duthie EA. … Application of Human Error Theory in Case Analysis of Wrong Procedures. … https://psnet.ahrq.gov/issue/application-human-error-theory-case-analysis-wrong-procedures This study … examines five wrong-procedure cases by applying James Reason’s human error theory, and describes the … https://psnet.ahrq.gov/issue/application-human-error-theory-case-analysis-wrong-procedures https://psnet.ahrq.gov

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42348/psn-pdf
    March 04, 2015 - Increasing rate of detection of wrong-patient radiographs: use of photographs obtained at time of radiography … Increasing Rate of Detection of Wrong-Patient Radiographs: Use of Photographs Obtained at Time of Radiography … https://psnet.ahrq.gov/issue/increasing-rate-detection-wrong-patient-radiographs-use-photographs- obtained-time-radiography … https://psnet.ahrq.gov/issue/increasing-rate-detection-wrong-patient-radiographs-use-photographs-obtained-time-radiography … https://psnet.ahrq.gov/issue/increasing-rate-detection-wrong-patient-radiographs-use-photographs-obtained-time-radiography

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40142/psn-pdf
    April 04, 2011 - Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery. … Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery. … https://psnet.ahrq.gov/issue/prevention-3-never-events-operating-room-fires-gossypiboma-and-wrong-site … https://psnet.ahrq.gov/issue/prevention-3-never-events-operating-room-fires-gossypiboma-and-wrong-site-surgery … https://psnet.ahrq.gov/issue/prevention-3-never-events-operating-room-fires-gossypiboma-and-wrong-site-surgery

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42360/psn-pdf
    April 16, 2018 - Wrong-patient medication errors: an analysis of event reports in Pennsylvania and strategies for prevention … https://psnet.ahrq.gov/issue/wrong-patient-medication-errors-analysis-event-reports-pennsylvania-and- … strategies-prevention This analysis of reports submitted to the Pennsylvania Patient Safety Authority discusses why wrong … https://psnet.ahrq.gov/issue/wrong-patient-medication-errors-analysis-event-reports-pennsylvania-and-strategies-prevention … https://psnet.ahrq.gov/issue/wrong-patient-medication-errors-analysis-event-reports-pennsylvania-and-strategies-prevention

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48193/psn-pdf
    August 28, 2019 - Automated detection of wrong-drug prescribing errors. … Automated detection of wrong-drug prescribing errors. … https://psnet.ahrq.gov/issue/automated-detection-wrong-drug-prescribing-errors Look-alike and sound-alike … https://psnet.ahrq.gov/issue/automated-detection-wrong-drug-prescribing-errors https://psnet.ahrq.gov

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43819/psn-pdf
    July 16, 2015 - Intercepting wrong-patient orders in a computerized provider order entry system. … Intercepting wrong-patient orders in a computerized provider order entry system. … https://psnet.ahrq.gov/issue/intercepting-wrong-patient-orders-computerized-provider-order-entry-system … A forcing function that mandated correct patient identification resulted in a moderate decrease in wrong-patient … https://psnet.ahrq.gov/issue/intercepting-wrong-patient-orders-computerized-provider-order-entry-system

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43842/psn-pdf
    January 28, 2015 - Should health care providers be forced to apologise after things go wrong? … Should health care providers be forced to apologise after things go wrong? … https://psnet.ahrq.gov/issue/should-health-care-providers-be-forced-apologise-after-things-go-wrong … https://psnet.ahrq.gov/issue/should-health-care-providers-be-forced-apologise-after-things-go-wrong https … apology-errors-whose-responsibility https://psnet.ahrq.gov/issue/more-words-patients-views-apology-and-disclosure-when-things-go-wrong-cancer-care

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41952/psn-pdf
    January 16, 2013 - Prevention of a wrong-location misadministration through the use of an intradepartmental incident learning … Prevention of a wrong-location misadministration through the use of an intradepartmental incident learning … https://psnet.ahrq.gov/issue/prevention-wrong-location-misadministration-through-use-intradepartmental … https://psnet.ahrq.gov/issue/prevention-wrong-location-misadministration-through-use-intradepartmental-incident-learning … https://psnet.ahrq.gov/issue/prevention-wrong-location-misadministration-through-use-intradepartmental-incident-learning

  13. DTaP–Tdap mix-ups now affecting hundreds of patients. | PSNet

    psnet.ahrq.gov/issue/dtap-tdap-mix-ups-now-affecting-hundreds-patients
    June 10, 2018 - June 16, 2019 Oops, sorry, wrong patient! … Site, Wrong Procedure and Wrong Person Surgery. … February 9, 2011 The wrong foot, and other tales of surgical error. … February 8, 2011 Wrong-site craniotomy: analysis of 35 cases and systems for prevention … July 23, 2010 Avoiding wrong site surgery: a systematic review.

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40132/psn-pdf
    May 25, 2011 - Information needs in operating room teams: what is right, what is wrong, and what is needed? … Information needs in operating room teams: what is right, what is wrong, and what is needed? … https://psnet.ahrq.gov/issue/information-needs-operating-room-teams-what-right-what-wrong-and-what- … https://psnet.ahrq.gov/issue/information-needs-operating-room-teams-what-right-what-wrong-and-what-needed … https://psnet.ahrq.gov/issue/information-needs-operating-room-teams-what-right-what-wrong-and-what-needed

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45430/psn-pdf
    September 28, 2016 - Understanding and responding when things go wrong: key principles for primary care educators. … Understanding and responding when things go wrong: key principles for primary care educators. … https://psnet.ahrq.gov/issue/understanding-and-responding-when-things-go-wrong-key-principles-primary … https://psnet.ahrq.gov/issue/understanding-and-responding-when-things-go-wrong-key-principles-primary-care-educators … https://psnet.ahrq.gov/issue/understanding-and-responding-when-things-go-wrong-key-principles-primary-care-educators

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43294/psn-pdf
    April 25, 2016 - The right and wrong way to talk to patients about adverse events. … The right and wrong way to talk to patients about adverse events. … https://psnet.ahrq.gov/issue/right-and-wrong-way-talk-patients-about-adverse-events Apology laws have … https://psnet.ahrq.gov/issue/right-and-wrong-way-talk-patients-about-adverse-events https://psnet.ahrq.gov … narrative-review-do-state-laws-make-it-easier-say-im-sorry https://psnet.ahrq.gov/issue/when-things-go-wrong-responding-adverse-events

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44394/psn-pdf
    August 24, 2018 - Getting the wrong person's medicine at the pharmacy: easy steps consumers can take to help eliminate … https://psnet.ahrq.gov/issue/getting-wrong-persons-medicine-pharmacy-easy-steps-consumers-can-take- … newsletter article describes how correctly completed medication orders can inadvertently be given to the wrong … https://psnet.ahrq.gov/issue/getting-wrong-persons-medicine-pharmacy-easy-steps-consumers-can-take-help-eliminate-these … https://psnet.ahrq.gov/issue/getting-wrong-persons-medicine-pharmacy-easy-steps-consumers-can-take-help-eliminate-these

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43368/psn-pdf
    October 01, 2014 - Operating room briefings or time-outs are mandated by The Joint Commission as a strategy to prevent wrong-site … improving-safety-and-quality-care-enhanced-teamwork-through-operating-room-briefings https://psnet.ahrq.gov/issue/operating-room-briefings-and-wrong-site-surgery … https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery https://psnet.ahrq.gov

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38332/psn-pdf
    January 14, 2009 - periodic audits and feedback to increase compliance with patient identification in the prevention of wrong-patient … and wrong-site surgery. … A related commentary [see link below] discusses the broader context of efforts to eliminate wrong-site … verifying-patient-identity-and-site-surgery-improving-compliance-protocol-audit-and-feedback https://psnet.ahrq.gov/issue/wrong-patient … https://psnet.ahrq.gov/issue/incidence-patterns-and-prevention-wrong-site-surgery

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50681/psn-pdf
    November 20, 2019 - The wrong goodbye. November 20, 2019 Sexton J, Schweber N. ProPublica. October 31, 2019. … https://psnet.ahrq.gov/issue/wrong-goodbye Misidentification of patients can cause harm. … https://psnet.ahrq.gov/issue/wrong-goodbye https://psnet.ahrq.gov/web-mm/mistaken-identity
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