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Showing results for "wrong".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41958/psn-pdf
    April 17, 2013 - https://psnet.ahrq.gov/issue/surgical-never-events-united-states More than a decade ago, stories of wrong … An incident of wrong-site surgery is discussed in an AHRQ WebM&M commentary. … https://psnet.ahrq.gov/issue/surgical-never-events-united-states https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43416/psn-pdf
    August 13, 2014 - Compliance with a time-out procedure intended to prevent wrong surgery in hospitals: results of a national … Compliance with a time-out procedure intended to prevent wrong surgery in hospitals: results of a national … https://psnet.ahrq.gov/issue/compliance-time-out-procedure-intended-prevent-wrong-surgery-hospitals- … https://psnet.ahrq.gov/issue/compliance-time-out-procedure-intended-prevent-wrong-surgery-hospitals-results-national … https://psnet.ahrq.gov/issue/compliance-time-out-procedure-intended-prevent-wrong-surgery-hospitals-results-national

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50727/psn-pdf
    December 11, 2019 - Your diagnosis was wrong. Could doctor bias have been a factor? December 11, 2019 Glicksman E. … https://psnet.ahrq.gov/issue/your-diagnosis-was-wrong-could-doctor-bias-have-been-factor Unconscious … https://psnet.ahrq.gov/issue/your-diagnosis-was-wrong-could-doctor-bias-have-been-factor https://psnet.ahrq.gov

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36945/psn-pdf
    May 20, 2019 - psnet.ahrq.gov/issue/national-time-out-day https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37914/psn-pdf
    August 06, 2008 - Hospital tells of surgery on wrong side. August 6, 2008 Smith S. … https://psnet.ahrq.gov/issue/hospital-tells-surgery-wrong-side This article reports on a wrong-side … https://psnet.ahrq.gov/issue/hospital-tells-surgery-wrong-side

  6. A chemotherapy incident reporting and improvement system. | PSNet

    psnet.ahrq.gov/issue/chemotherapy-incident-reporting-and-improvement-system
    November 16, 2022 - March 28, 2011 Patients use an internet technology to report when things go wrong. … December 15, 2010 Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37492/psn-pdf
    March 18, 2010 - Insight into preventing wrong-site surgery. … https://psnet.ahrq.gov/issue/insight-preventing-wrong-site-surgery This article summarizes a state-level … analysis that used site visits along with near miss and error reports to evaluate wrong-site surgeries … https://psnet.ahrq.gov/issue/insight-preventing-wrong-site-surgery

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37973/psn-pdf
    November 28, 2016 - When it's surgery, don't get it wrong. November 28, 2016 Grant T. … https://psnet.ahrq.gov/issue/when-its-surgery-dont-get-it-wrong This article reports on a wrong-sided … https://psnet.ahrq.gov/issue/when-its-surgery-dont-get-it-wrong https://psnet.ahrq.gov//#nearmiss

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39906/psn-pdf
    July 08, 2013 - issue/safe-site-invasive-procedure-non-operating-room This protocol is designed to protect against wrong-site … /psnet.ahrq.gov/issue/safe-site-invasive-procedure-non-operating-room https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery

  10. Blackbox: A Multidisciplinary Team-Based Framework for HIT Error Pattern Detection - Final Report (pdf file)

    digital.ahrq.gov/sites/default/files/docs/citation/r21hs024755-hettinger-final-report-2019.pdf
    January 01, 2019 - Cases of interest across five error types (including wrong route, wrong weight and wrong dose among … Each of the error types (Wrong Route, Wrong Weight, etc.) will be explored in greater detail below. … the wrong route. … Wrong Side Wrong sided surgeries are a never event in modern healthcare yet they continue to happen … Order written for wrong patient and then voided with reason "wrong patient/wrong encounter".

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44238/psn-pdf
    November 03, 2015 - https://psnet.ahrq.gov/issue/use-temporary-names-newborns-and-associated-risks Wrong-patient errors … temporary names if they don't have a name immediately after birth, and this may increase the rates of wrong-patient … that implementing specific first names that incorporated the mother's name reduced the incidence of wrong-patient … psnet.ahrq.gov/issue/use-temporary-names-newborns-and-associated-risks https://psnet.ahrq.gov/issue/wrong-patient … https://psnet.ahrq.gov/primer/never-events https://psnet.ahrq.gov/issue/understanding-and-preventing-wrong-patient-electronic-orders-randomized-controlled-trial

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40194/psn-pdf
    June 20, 2011 - What happens when things go wrong? June 20, 2011 Brandom BW, Callahan P, Micalizzi DA. … What happens when things go wrong? … https://psnet.ahrq.gov/issue/what-happens-when-things-go-wrong This commentary reveals a personal story … https://psnet.ahrq.gov/issue/what-happens-when-things-go-wrong

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37009/psn-pdf
    March 18, 2010 - Doing the "right" things to correct wrong-site surgery. … March 18, 2010 Patient Safety Advisory https://psnet.ahrq.gov/issue/doing-right-things-correct-wrong-site-surgery … This article discusses reports of wrong-site surgery submitted to the PA-PSRS, compares them with results … https://psnet.ahrq.gov/issue/doing-right-things-correct-wrong-site-surgery https://psnet.ahrq.gov/issue

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44180/psn-pdf
    June 21, 2015 - intended to refer to adverse events that were both clinically devastating and largely preventable—such as wrong-site … A case of a wrong-site surgery is discussed in a recent AHRQ WebM&M commentary. … primer/never-events https://psnet.ahrq.gov/issue/national-quality-forum https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37990/psn-pdf
    August 13, 2008 - Most surgery in wrong spot done on spine: 11 such cases found in state since 2006. … https://psnet.ahrq.gov/issue/most-surgery-wrong-spot-done-spine-11-such-cases-found-state-2006 This … article reports on the incidence of wrong site surgeries in Massachusetts and describes complex factors … https://psnet.ahrq.gov/issue/most-surgery-wrong-spot-done-spine-11-such-cases-found-state-2006

  16. Litigation related to inadequate anaesthesia: an analysis of claims against the NHS in England 1995-2007. | PSNet

    psnet.ahrq.gov/issue/litigation-related-inadequate-anaesthesia-analysis-claims-against-nhs-england-1995-2007
    November 16, 2022 - 2014 Assessment of the implementation of a national patient safety alert to reduce wrong … February 15, 2023 View More Related Resources Insurance claims for wrong-side … , wrong-organ, wrong-procedure, or wrong-person surgical errors: a retrospective study for 10 years.

  17. Representative case series from public hospital admissions 1998 II: surgical adverse events. | PSNet

    psnet.ahrq.gov/issue/representative-case-series-public-hospital-admissions-1998-ii-surgical-adverse-events
    June 07, 2023 - December 22, 2010 Operating room briefings and wrong-site surgery. … June 22, 2009 Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events

  18. The 5th anniversary of the "Universal Protocol": pitfalls and pearls revisited. | PSNet

    psnet.ahrq.gov/issue/5th-anniversary-universal-protocol-pitfalls-and-pearls-revisited
    December 21, 2014 - and wrong-patient procedures in the Universal Protocol era: analysis of a prospective database of physician … Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong … Site, Wrong Procedure and Wrong Person Surgery. … February 9, 2011 The wrong foot, and other tales of surgical error. … September 24, 2008 Incidence, patterns, and prevention of wrong-site surgery.

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41698/psn-pdf
    November 27, 2012 - on a patient's legs, this article reveals how hospital protocol and medical record review prevented wrong-site … https://psnet.ahrq.gov/issue/duplication-surgical-site-marking https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39381/psn-pdf
    March 17, 2010 - Getting it right when things go wrong. March 17, 2010 Pettker CM, Funai EF. … Getting it right when things go wrong. JAMA. 2010;303(10):977-8. doi:10.1001/jama.2010.256. … https://psnet.ahrq.gov/issue/getting-it-right-when-things-go-wrong This brief commentary discusses the … https://psnet.ahrq.gov/issue/getting-it-right-when-things-go-wrong https://psnet.ahrq.gov/issue/balancing-no-blame-accountability-patient-safety
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