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Showing results for "wrong".

41. Assess Risk of Wrong-Patient Errors in an EMR That Allows Multiple Records Open | Digital Healthcare Research
    digital.ahrq.gov/ahrq-funded-projects/assess-risk-wrong-patient-errors-emr-allows-multiple-records-open
    January 01, 2023 - Assess Risk of Wrong-Patient Errors in an EMR That Allows Multiple Records Open Project … Compare the incidence of wrong-patient orders in a “restricted environment” that limits its providers … Assess Risk of Wrong Patient Errors in an EMR That Allows Multiple Records Open - Final Report. … Having multiple EHRs open simultaneously does not increase wrong-patient orders. … “Placing orders on the wrong patient should never happen.

42. Automated detection of wrong-drug prescribing errors. | Digital Healthcare Research
    digital.ahrq.gov/ahrq-funded-projects/tools-optimizing-medication-safety-top-meds/citation/automated
    January 01, 2023 - Automated detection of wrong-drug prescribing errors. … Automated detection of wrong-drug prescribing errors.

43. Two Wrongs Don't Make a Right (Kidney) | PSNet
    psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney
    April 01, 2010 - Wrong-side surgery is a surgical procedure that involves operating on the wrong extremity or wrong side … Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. … Wrong Site All surgical procedures performed on the wrong body part or wrong patient. … Often used as a general term for wrong level or part, wrong patient, and wrong side surgery. … Site, Wrong Procedure and Wrong Person Surgery.

44. Serious hazards of transfusion: evaluating the dangers of a wrong patient autologous salvaged blood in cardiac surgery. | PSNet
    psnet.ahrq.gov/issue/serious-hazards-transfusion-evaluating-dangers-wrong-patient-autologous-salvaged-blood
    May 11, 2022 - Commentary Serious hazards of transfusion: evaluating the dangers of a wrong patient … Serious hazards of transfusion: evaluating the dangers of a wrong patient autologous salvaged blood in … Wrong-patient transfusion errors can lead to serious patient harm. … Serious hazards of transfusion: evaluating the dangers of a wrong patient autologous salvaged blood in … March 2, 2022 Wrong-patient blood transfusion error: leveraging technology to overcome

45. When Things Go Wrong: Responding to Adverse Events. | PSNet
    psnet.ahrq.gov/issue/when-things-go-wrong-responding-adverse-events
    November 19, 2014 - Book/Report Classic When Things Go Wrong: Responding to … Citation Text: When Things Go Wrong: Responding to Adverse Events. … Copy URL Cite Citation Citation Text: When Things Go Wrong

46. Wrong-side thoracentesis: lessons learned from root cause analysis. | PSNet
    psnet.ahrq.gov/issue/wrong-side-thoracentesis-lessons-learned-root-cause-analysis
    July 16, 2015 - Study Wrong-side thoracentesis: lessons learned from root cause analysis. … Wrong-side thoracentesis: lessons learned from root cause analysis. … Wrong-side thoracentesis: lessons learned from root cause analysis. … May 6, 2015 Wrong-site and wrong-patient procedures in the Universal Protocol era: analysis … September 15, 2010 Wrong site surgery near misses and actual occurrences.

47. Never Events | PSNet
    psnet.ahrq.gov/primer/never-events
    June 15, 2024 - site Surgery or other invasive procedure performed on the wrong patient Wrong surgical or other invasive … drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration … Since February 2009, CMS has not paid for any costs associated with  wrong-site surgeries . … , Wrong-Procedure, and Wrong-Patient Surgery December 15, 2024 Editor's Picks Sentinel … , Wrong-Procedure, and Wrong-Patient Surgery December 15, 2024 Identifying

48. Health information technology-related wrong-patient errors: context is critical. | PSNet
    psnet.ahrq.gov/issue/health-information-technology-related-wrong-patient-errors-context-critical
    June 01, 2022 - Study Health information technology-related wrong-patient errors: context is critical … Citation Text: Health information technology-related wrong-patient errors: context is critical. … This study analyzed the processes of care involved in 1,189 wrong-patient events.  … reached the patient, most commonly involving inappropriate medication administration or receiving the wrong … The authors recommend several strategies for reducing wrong-patient errors. 

49. Adding automation and independent dual verification to reduce wrong blood in tube (WBIT) events. | PSNet
    psnet.ahrq.gov/issue/adding-automation-and-independent-dual-verification-reduce-wrong-blood-tube-wbit-events
    October 21, 2020 - Study Adding automation and independent dual verification to reduce wrong blood in … Adding automation and independent dual verification to reduce wrong blood in tube (WBIT) events. … Wrong blood in tube (WBIT) errors are rare but can lead to complications . … Adding automation and independent dual verification to reduce wrong blood in tube (WBIT) events. … June 2, 2019 Wrong-patient blood transfusion error: leveraging technology to overcome

50. Effect of restriction of the number of concurrently open records in an electronic health record on wrong-patient order errors: a randomized clinical trial. | PSNet
    psnet.ahrq.gov/issue/effect-restriction-number-concurrently-open-records-electronic-health-record-wrong-patient
    July 09, 2018 - Effect of restriction of the number of concurrently open records in an electronic health record on wrong-patient … Effect of Restriction of the Number of Concurrently Open Records in an Electronic Health Record on Wrong-Patient … September 4, 2019 Evaluating serial strategies for preventing wrong-patient orders in … June 2, 2019 Wrong-patient blood transfusion error: leveraging technology to overcome … September 1, 2016 Intercepting wrong-patient orders in a computerized provider order

51. Providing Evidence and Developing a Toolkit to Accelerate the Adoption of Patient Photographs in Electronic Health Records | Digital Healthcare Research
    digital.ahrq.gov/ahrq-funded-projects/providing-evidence-and-developing-toolkit-accelerate-adoption-patient
    July 31, 2023 - for identifying wrong-patient orders that is endorsed by major patient safety organizations. … Wrong patient orders were identified by using the Wrong-Patient Retract-and-Reorder Measure (WP-RAR), … a validated, reliable, and automated method for identifying wrong-patient orders developed by Dr. … Having multiple EHRs open simultaneously does not increase wrong-patient orders. … “Placing orders on the wrong patient should never happen.

52. Wrong-patient blood transfusion error: leveraging technology to overcome human error in intraoperative blood component administration. | PSNet
    psnet.ahrq.gov/issue/wrong-patient-blood-transfusion-error-leveraging-technology-overcome-human-error
    December 09, 2020 - Study Wrong-patient blood transfusion error: leveraging technology to overcome human … Wrong-Patient Blood Transfusion Error: Leveraging Technology to Overcome Human Error in Intraoperative … Following a sentinel wrong-patient event , a multidisciplinary quality improvement team worked to enhance … Wrong-Patient Blood Transfusion Error: Leveraging Technology to Overcome Human Error in Intraoperative … May 10, 2023 Adding automation and independent dual verification to reduce wrong blood

53. Wrong-patient ordering errors in peripartum mother-newborn pairs: a unique patient-safety challenge in obstetrics. | PSNet
    psnet.ahrq.gov/issue/wrong-patient-ordering-errors-peripartum-mother-newborn-pairs-unique-patient-safety-challenge
    July 28, 2021 - Commentary Wrong-patient ordering errors in peripartum mother-newborn pairs: a unique … Wrong-patient ordering errors in peripartum mother-newborn pairs: a unique patient-safety challenge in … This commentary presents two cases of near-miss wrong-patient order errors between mother-newborn pairs … Wrong-patient ordering errors in peripartum mother-newborn pairs: a unique patient-safety challenge in … November 30, 2022 Risk of wrong-patient orders among multiple vs singleton births in

54. Wrong-site surgery, retained surgical items, and surgical fires: a systematic review of surgical never events. | PSNet
    psnet.ahrq.gov/issue/wrong-site-surgery-retained-surgical-items-and-surgical-fires-systematic-review-surgical
    March 13, 2013 - Review Wrong-site surgery, retained surgical items, and surgical fires: a systematic … Wrong-Site Surgery, Retained Surgical Items, and Surgical Fires : A Systematic Review of Surgical Never … Incidence estimates for retained surgical items and wrong-site surgery varied across studies, with … April 7, 2021 Concept analysis: wrong-site surgery. … site, wrong procedure, and wrong patient operations.

55. Reducing the Risks of Wrong-Site Surgery: Safety Practices from The Joint Commission Center for Transforming Healthcare Project. | PSNet
    psnet.ahrq.gov/issue/reducing-risks-wrong-site-surgery-safety-practices-joint-commission-center-transforming
    October 19, 2016 - Book/Report Reducing the Risks of Wrong-Site Surgery: Safety Practices from The Joint … Citation Text: Reducing the Risks of Wrong-Site Surgery: Safety Practices from The Joint Commission … Wrong-site surgery is a never event , but still occurs at alarming rates. … Charles Vincent discussed a case of a wrong-site procedure. … January 4, 2012 Incidence, patterns, and prevention of wrong-site surgery.

56. Indication alerts to improve problem list documentation. | Digital Healthcare Research
    digital.ahrq.gov/ahrq-funded-projects/preventing-wrong-drug-and-wrong-patient-errors-indication-alerts-cpoe-systems/citation/indication
    January 01, 2023 - pubmed.ncbi.nlm.nih.gov/34957491/ Principal Investigator Lambert, Bruce Project Name Preventing Wrong-Drug … and Wrong-Patient Errors With Indication Alerts in CPOE Systems Technology Clinical Decision

57. Making Healthcare Safer Practices: 11. Patient Identification Errors in the Operating Room (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/patient-id-errors-1.pdf
    March 01, 2020 - , wrong- procedure, and wrong-person surgery. … , Wrong Procedure and Wrong Person Surgery. … Site, Wrong Procedure, Wrong Person Surgery Operating room The estimated rate of wrong-site … *" OR "Wrong Site Surger*" OR "Wrong-Site Surger*" OR "Surger*, Wrong-Site" OR "Surger*, Wrong Site … *" OR "Wrong Site Surger*" OR "Wrong-Site Surger*" OR "Surger*, Wrong-Site" OR "Surger*, Wrong Site

58. Assess Risk of Wrong Patient Errors in an EMR that Allows Multiple Records Open - Final Report (pdf file)
    digital.ahrq.gov/sites/default/files/docs/citation/r21hs023704-adelman-final-report-2019.pdf
    January 01, 2019 - The primary outcome was wrong-patient order sessions, including at least one wrong- patient order identified … Wrong-patient order sessions per 100,000 122.5 139.2 1.00 (0.68 to 1.46) 1.00 Wrong-patient order … Critical care Wrong-patient orders per 100,000 117.7 120.8 Wrong-patient orders 215 301 Total … orders 182,698 249,252 Pediatrics Wrong-patient orders per 100,000 54.4 58.6 Wrong-patient … Wrong-patient order sessions per 100,000 112.2 150.5 0.73 (0.50 to 1.06) .10 Wrong-patient order

59. Assessment of the implementation of a national patient safety alert to reduce wrong site surgery. | PSNet
    psnet.ahrq.gov/issue/assessment-implementation-national-patient-safety-alert-reduce-wrong-site-surgery
    March 28, 2011 - Study Assessment of the implementation of a national patient safety alert to reduce wrong … Assessment of the implementation of a national patient safety alert to reduce wrong site surgery. … Wrong-site surgery is a rare yet devastating outcome. … Assessment of the implementation of a national patient safety alert to reduce wrong site surgery. … March 29, 2012 Wrong site surgery.

60. Displaying Patient Photos in Medical Records Reduces Errors, Improves Patient Safety | Digital Healthcare Research
    digital.ahrq.gov/program-overview/research-stories/displaying-patient-photos-medical-records-reduces-errors-improves
    January 01, 2023 - Wrong patient orders can harm patients While digital solutions like computerized provider order entry … systems have reduced medical errors and improved patient safety, the risk of placing orders for the wrong … “Orders placed on the wrong patient should be a ‘never event,’ as in it should never happen,” said Dr … Wrong patient orders were identified by using the Wrong-Patient Retract-and-Reorder Measure (WP-RAR), … a validated, reliable, and automated method for identifying wrong-patient orders developed by Dr.