Results

Total Results: 1,736 records

Showing results for "wrong".

401. Breaking Down Barriers to Aseptic Catheter Insertion (May 12, 2015) | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/archived-webinars/breaking-down-barriers-transcript.html
     December 01, 2017 - I got tongue tied at the wrong point in the conversation, so thanks so much for that. … But maybe I'm wrong about that. … If I'm not wrong, we can think of a way, perhaps, to deal with some of the barriers that we saw, and … Something can go wrong at any point. … I keep pushing the wrong button to advance the slide, sorry.

402. Breaking-Down-Barriers-Transcript (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/breaking-down-barriers-transcript.docx
     May 12, 2015 - I got tongue tied at the wrong point in the conversation, so thanks so much for that. … Maybe I'm wrong, but my guess is that our hospital and our experience is not unique. … But maybe I'm wrong about that. … Something can go wrong at any point. … I keep pushing the wrong button to advance the slide, sorry.

403. An Etiology for Medication Ordering Errors in Computerized Provider Order Entry Systems | Digital Healthcare Research
     digital.ahrq.gov/ahrq-funded-projects/etiology-medication-ordering-errors-computerized-provider-order-entry-systems
     January 01, 2023 - The VAT was triggered for duplicate orders, drug interactions, orders placed for the wrong patient or … encounter, and orders with the wrong medication route, dosage, schedule, or strength.

404. EHR audit logs: a new goldmine for health services research? | Digital Healthcare Research
     digital.ahrq.gov/ahrq-funded-projects/assess-risk-wrong-patient-errors-emr-allows-multiple-records-open/citation/goldmine
     January 01, 2023 - Project Name Assess Risk of Wrong-Patient Errors in an EMR That Allows Multiple Records Open Develop

405. Primers | PSNet
     psnet.ahrq.gov/primers-0
     March 15, 2025 - (1) Fatigue and Sleep Deprivation (2) Identification Errors (2) Wrong … Intraoperative Complications (4) Retained Surgical Instruments and Sponges (3) Wrong-Site … Safety I defines safety as having as few things go wrong as possible whereas the Safety II perspective

406. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33592/psn-pdf
     December 15, 2024 - Errors are defined as "an act of commission (doing something wrong) or omission (failing to do the right … Error: a broader term referring to any act of commission (doing something wrong) or omission (failing

407. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47336/psn-pdf
     March 04, 2019 - psnet.ahrq.gov/issue/improving-patient-family-and-clinician-experience-after-harmful-events-when-things-go-wrong

408. Inadvertent Castration | PSNet
     psnet.ahrq.gov/web-mm/inadvertent-castration
     October 27, 2010 - Wrong-site Surgery and Other Cognitive Errors In this case, the surgeon almost certainly never considered … misalignment of the stars links this case and many other common intra-operative adverse events involving wrong-site … Strategies to avoid wrong-site surgery. In: Shojania KG, Duncan BW, McDonald KM, Wachter RM, eds. … March 3, 2011 Information needs in operating room teams: what is right, what is wrong

409. Enhancing Medication CPOE Safety and Quality by Indications-Based Prescribing | Digital Healthcare Research
     digital.ahrq.gov/ahrq-funded-projects/enhancing-medication-cpoe-safety-and-quality-indications-based-prescribing
     January 01, 2023 - Medication errors may also occur during the prescribing process, including prescribing the wrong medication … , wrong dose, or the wrong frequency of taking the medication.

410. Incident Reporting: More Attention to the Safety Action Feedback Loop, Please | PSNet
     psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please
     September 01, 2011 - Another problem is that the wrong types of events tend to get reported. … So, I would say reporting the wrong type of events is another problem, meaning that incident reports … What is it about a fall that's different than a wrong-site surgery that—assuming it was painless and … You could imagine what some of them would be, any time there's a wrong patient involved or a wrong medication … Whereas a lot of other incidents and serious things like wrong-site surgery where there will be so many

411. Polypharmacy | PSNet
     psnet.ahrq.gov/web-mm/polypharmacy
     March 01, 2007 - WebM&M Cases Medication Errors in Retail Pharmacies: Wrong … Patient, Wrong Instructions. … February 1, 2012 WebM&M Cases Bad Writing, Wrong

412. Terminology and Language Used by Patients and Caregivers | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-terminology8.html
     April 01, 2025 - When things go wrong, they may speak not of errors, but rather mistakes, problems, mishaps, misunderstandings

413. Why Checklists for Diagnosis Are Not Performing as Expected | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxchecklists-5.html
     September 01, 2020 - task but erred only in the execution (e.g., forgetting a step in the preoperative process, marking the wrong

414. Electronic Health Records | PSNet
     psnet.ahrq.gov/primer/electronic-health-records
     March 15, 2025 - that, while overall medication safety improved, new vulnerabilities emerged, including increases in wrong … patient, wrong medication, or wrongly timed orders.

415. Module 2: Urinary Catheter Maintenance | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/cauti-icu/facil-guide/mod2.html
     February 01, 2023 - 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

416. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74239/psn-pdf
     January 12, 2022 - https://psnet.ahrq.gov/issue/high-risk-medications-hospitalized-elderly-adults-are-we-making-it-easy-do-wrong-thing

417. On O.R. Off? | PSNet
     psnet.ahrq.gov/web-mm/or
     August 22, 2013 - recurrent elements in unanticipated adverse events.( 1 ) As a practicing anesthesiologist, I have had the wrong … Many things had to go wrong for all these mistakes (ie, the "holes in the This error was the result of … Many things had to go wrong for all these mistakes (ie, the "holes in the Swiss cheese") to line up.( … January 29, 2014 When surgery goes wrong: weighing up the risks.

418. 170-Cusp-Science-Safety-Notes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/170-cusp-science-safety-notes.docx
     October 01, 2024 - Safe systems have a mechanism to learn from events when something goes wrong. … For example, an anesthesiologist gives a patient the wrong antibiotic or the wrong dose of an antibiotic … Slide 23 What’s Wrong With This Picture?

419. 2022 Updated Results for the AHRQ Surveys on Patient Safety CultureTM (SOPS®) Diagnostic Safety Supplemental Items for Medical Offices (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/DxSftyRpt-Updated-2022.pdf
     January 01, 2022 - reporting system that has a specific coded category to document diagnostic errors such as missed, wrong … diagnosis; communicating with providers who may have missed a diagnosis; and being informed when a missed, wrong … (Item DXC3, NA/DK/MI = 49%) 55 When a missed, wrong, or delayed diagnosis happens in this office, … (Item DXC3) 51% 69% 55% 55% 62% 47% When a missed, wrong, or delayed diagnosis happens in this office … (Item DXC3) 58% 54% 58% When a missed, wrong, or delayed diagnosis happens in this office, we are informed

420. NAA National Webinar August 2024 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/action-alliance-webinar-august-2024.pdf
     January 01, 2024 - Alignment with Surgery Rotations https://www.aorn.org/outpatient-surgery/article/the-big- three-wrong-site-specialties … orthopedics, neurosurgery, urology https://www.aorn.org/outpatient-surgery/article/the-big-three-wrong-site-specialties … https://www.aorn.org/outpatient-surgery/article/the-big-three-wrong-site-specialties © 2023-2024