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Total Results: 1,736 records

Showing results for "wrong".

421. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33563/psn-pdf
     September 16, 2024 - web-mm/implicit-biases-interprofessional-communication-and-power-dynamics https://psnet.ahrq.gov/issue/wrong-patient … https://psnet.ahrq.gov/issue/wrong-patient https://psnet.ahrq.gov/issue/surveys-patient-safety-culture

422. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33568/psn-pdf
     June 15, 2024 - /dont-wait-collect-accurate-weight-case-subtherapeutic-insulin-therapy https://psnet.ahrq.gov/issue/wrong-patient … Current Context The Joint Commission has mandated use of RCA to analyze sentinel events (such as wrong-site

423. Archived: Evidence Summary: Depression in Children and Adolescents: Screening | United States Preventive Services Taskforce
     www.uspreventiveservicestaskforce.org/uspstf/document/evidence-summary/depression-in-children-and-adolescents-screening
     February 08, 2016 - After full-text review, 361 were excluded: 36 for wrong publication type/not original research, 171 for … wrong population, 51 for wrong comparator, 29 for wrong outcome, 0 for wrong timing, 7 for wrong setting … , 0 for wrong geographical setting, 15 for wrong study design, 23 for wrong intervention, 0 for wrong … sample size for cohort studies, 12 for wrong publication dates, 6 for wrong language/non-English, 5

424. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73190/psn-pdf
     April 28, 2021 - flaw-medicine-addressing-racial-and-gender-disparities-critical-care https://psnet.ahrq.gov/issue/your-diagnosis-was-wrong-could-doctor-bias-have-been-factor

425. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36442/psn-pdf
     July 23, 2023 - evaluating-efforts-optimize-teamstepps-implementation-surgical-and-pediatric-intensive-care https://psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong

426. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867651/psn-pdf
     February 26, 2025 - Definition of Safety and Safety Management Principle Safety I defies safety as having as few things go wrong … causality credo, which he defines as “the belief that adverse outcomes happen because something goes wrong … intractability, and complexity of healthcare work, the surprise is not that things occasionally go wrong … Rather than reacting retrospectively to what has gone wrong, Safety II attempts to understand the interaction … proposes to understand how things usually go right as a basis for explaining how things occasionally go wrong

427. Safety I, Safety II, and the New Views of Safety | PSNet
     psnet.ahrq.gov/primer/safety-i-safety-ii-and-new-views-safety
     October 02, 2024 - Definition of Safety and Safety Management Principle Safety I defies safety as having as few things go wrong … causality credo , which he defines as “the belief that adverse outcomes happen because something goes wrong … intractability, and complexity of healthcare work, the surprise is not that things occasionally go wrong … Rather than reacting retrospectively to what has gone wrong, Safety II attempts to understand the interaction … proposes to understand how things usually go right as a basis for explaining how things occasionally go wrong

428. Statistical Brief #29
     hcup-us.ahrq.gov/reports/statbriefs/sb29.jsp
     April 01, 2007 - categories— adverse effects of drugs properly administered and drug poisoning (accidental overdose, wrong … Most remaining ADEs were drug poisoning , which involve accidental drug overdose, wrong drugs taken … About 8.6 percent of ADEs (104,000 stays) were drug poisoning—accidental overdose, wrong drugs given … Poisoning by drugs, medicinal and biological substances (includes overdose of these substances and wrong … Accidental poisoning by drugs, medicinal substances, and biologicals (includes accidental overdose, wrong

429. Folic Acid Supplementation for the Prevention of Neural Tube Defects: An Updated Evidence Report and Systematic Review (pdf file)
     www.uspreventiveservicestaskforce.org/home/getfilebytoken/MWRHULpw6y_5Uk_KXTyvp8
     January 10, 2017 - publication type or not original research 28 Wrong publication 15 Wrong comparator 124 Wrong outcome … 2 Wrong timing 36 Wrong geographical setting 44 Wrong study design 98 Wrong intervention 1 Wrong sample … Wrong study design: Study did not include an eligible design. … Wrong sample size: Study had 50 or fewer participants. … Wrong language/non-English: Study was not published in English.

430. Active Error (or Active Failure) | PSNet
     psnet.ahrq.gov/glossary/active-error-or-active-failure
     September 13, 2021 - This person may literally be holding a scalpel (e.g., an orthopedist operating on the wrong leg) or figuratively

431. Slide 1 (ppt file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/health-literacy-pfe-070913.ppt
     July 01, 2013 - Focus on key messages and repeat Patients should leave you knowing 3 things: What is wrong? … Steps to Improve YOUR Skills * EXAMPLE 1: One Key Message for a Patient with a Catheter What’s wrong … EXAMPLE 2: One Key Message for a Patient with a Catheter * What’s wrong?

432. Tools for Optimizing Medication Safety (TOP-MEDS) - Final Report (pdf file)
     digital.ahrq.gov/sites/default/files/docs/citation/u19hs021093-lambert-final-report-2017.pdf
     January 01, 2017 - Drug name confusion causes patients to receive the wrong drugs. … In the United States, roughly one per thousand prescriptions results in the wrong drug being filled … Despite advances in computerized prescriber order entry (CPOE), wrong drug errors are still reported … and wrong-patient errors and improve the completeness of the problem list. … Develop and test wrong-drug error detection system 3.B.3. Aim 3.

433. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60306/psn-pdf
     May 06, 2020 - identified, 10.8% were due to a medication error; nearly all of these errors (93.2%) were attributed to the wrong

434. Screening for Major Depressive Disorder in Children and Adolescents: A Systematic Review for the USPSTF (pdf file)
     www.uspreventiveservicestaskforce.org/home/getfilebytoken/9H5mgkBCjNQVZZ4pnkNo6B
     February 01, 2016 - 9638) Full-text articles assessed for eligibility (n = 367) Full-text articles excluded (n = 361) Wrong … publication type/not original research: 36 Wrong population: 171 Wrong comparator: 51 … Wrong outcome: 29 Wrong timing: 0 Wrong setting: 7 Wrong geographical setting: 0 Wrong study … design: 15 Wrong intervention: 23 Wrong sample size for cohort studies: 0 Wrong publication … dates: 12 Wrong language/non-English: 6 Included in 2009 evidence synthesis: 5 Article irretrievable

435. Tool 6. Worksheet: Establishing Protocols for BMI Screening | Agency for Healthcare Research and Quality
     www.ahrq.gov/ncepcr/tools/obesity/obpcp-tool6.html
     May 01, 2014 - Scale in "wrong location?" Draft BMI screening protocols.

436. The Role of Bar Coding and Smart Pumps in Safety | PSNet
     psnet.ahrq.gov/perspective/role-bar-coding-and-smart-pumps-safety
     September 01, 2008 - While smart infusion pumps alone may prevent pump programming errors, they cannot prevent giving the wrong … drug or the wrong concentration, or giving the drug to the wrong patient. … multicenter study that included 24 hospitals, Barker found an administration error rate of 11%, excluding wrong-time … In both cases, errors led to the wrong concentration of IV heparin being administered, resulting in 1000 … Here, the barcode reader is connected to the smart pump to prevent wrong medication and wrong concentration

437. July Teleconference Transcript (pdf file)
     digital.ahrq.gov/sites/default/files/docs/July%20Teleconference%20Transcript.pdf
     June 16, 2021 - In other words something went wrong along the way. … Here’s our framework for what goes wrong basically. First we have the truth. … This is an example of a wrong medication alert. Sorry to go back. … The wrong medication alert and then a wrong patient alert. … So it says the scanned wristband is either the wrong patient or the wristband was unreadable.

438. Contingency Diagram | Digital Healthcare Research
     digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/contingency-diagram
     January 01, 2023 - BRAINSTORM how things can go wrong.

439. Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room | PSNet
     psnet.ahrq.gov/web-mm/saline-flush-leads-acute-paralysis-awake-patient-risks-improper-medication-labeling
     February 01, 2019 - events, 276 were medication errors, of which the most common type was accidental administration of the wrong … dose (N = 84), followed by accidental administration of the wrong syringe (N = 49). … Care Professions May 1, 2011 WebM&M Cases Wrong

440. Medication Without Harm - How Digital Healthcare Tools Can Support Providers and Improve Patient Safety | Digital Healthcare Research
     digital.ahrq.gov/national-webinars/medication-without-harm-how-digital-healthcare-tools-can-support-providers-and
     July 24, 2024 - Explain how outcome measures, such as the Wrong-Patient Retract-and-Reorder measure, can be developed