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Total Results: 1,736 records

Showing results for "wrong".

441. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49757/psn-pdf
     April 01, 2016 - The intern immediately notified the nurse that argatroban had been administered to the wrong patient … satisfaction.(7-9) Immersion into the situation of interest is the first step in recognizing what might be wrong … with the situation, and it supports the ability to anticipate what may go wrong in the future.

442. Health Literacy and Patient and Family Engagement: Strategic Tools to Prevent CAUTI | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/archived-webinars/health-literacy-slides.html
     December 01, 2017 - Skills Focus on key messages and repeat Patients should leave you knowing 3 things: What is wrong … Slide 26 Example 1: One Key Message for a Patient with a Catheter What’s wrong? … Slide 27 Example 2: One Key Message for a Patient with a Catheter What’s wrong?

443. Duplicate Therapies in Retail Pharmacy | PSNet
     psnet.ahrq.gov/web-mm/duplicate-therapies-retail-pharmacy
     August 05, 2022 - May 16, 2022 WebM&M Cases Wrong Catheter in the … WebM&M Cases Medication Errors in Retail Pharmacies: Wrong … Patient, Wrong Instructions. … Polypharmacy May 1, 2013 WebM&M Cases Bad Writing, Wrong

444. Failure Mode and Effect Analysis (FMEA) | PSNet
     psnet.ahrq.gov/glossary/failure-mode-and-effect-analysis-fmea
     September 13, 2021 - With the process mapped out, the FMEA then continues by identifying the ways in which each step can go wrong

445. Learning From Defects Through Sensemaking: Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-fac-notes.html
     December 01, 2017 - Are there aspects of the patient safety culture that promote doing the wrong things? … The attending anesthesiologist then read the wrong patient’s name on the blood transfusion bag. … Slide 27: Case Study: Renal Transplant Say: The attending anesthesiologist asked about the wrong … It was later determined that the wrong stamp had left the ICU with the patient at 5:30 a.m. … Frankly, wrong-site surgeries are too important a defect to merely hope for success.

446. Audit Log | Digital Healthcare Research
     digital.ahrq.gov/technology/audit-log
     January 01, 2023 - Project Name Assess Risk of Wrong-Patient Errors in an EMR That Allows Multiple Records Open Develop

447. In Conversation With… Erik Hollnagel, PhD | PSNet
     psnet.ahrq.gov/perspective/conversation-erik-hollnagel-phd
     February 26, 2025 - The basic idea is that even when something goes wrong, people were trying to do what they thought was … We can do it by helping people talk about their work, not talk about what has gone wrong but simply talk … what you do when things go well—rather than in the sense of Safety-I, finding the causes for what went wrong

448. Root Cause Analysis | PSNet
     psnet.ahrq.gov/primer/root-cause-analysis
     March 30, 2022 - Current Context The Joint Commission has mandated use of RCA to analyze sentinel events (such as wrong-site … July 20, 2022 View More Related WebM&M Root Cause Analysis Gone Wrong

449. Patient Post-Hospitalization Telephone Survey (pdf file)
     hcup-us.ahrq.gov/datainnovations/raceethnicitytoolkit/nm6.pdf
     June 16, 2014 - Not known /wrong number CODE OUT AS WRONG NUMBER INTERVIEWER NOTE: OK TO CALL OUT OF STATE TO COMPLETE

450. Which End Is Which? | PSNet
     psnet.ahrq.gov/web-mm/which-end-which
     February 09, 2011 - second is that a floppy, redundant transverse colon is misidentified as sigmoid colon, so that the wrong … step.( 1-3 ) In this case, the transverse colon was likely misidentified as the sigmoid colon, and the wrong … If the wrong end has been brought out, the scope will demonstrate normal colon lumen.

451. A Conversation with Patient Safety Officers. | PSNet
     psnet.ahrq.gov/issue/conversation-patient-safety-officers
     April 30, 2024 - August 17, 2021 Neuromuscular blocking agents: reducing associated wrong-drug errors.

452. HospitalInspections.org | PSNet
     psnet.ahrq.gov/issue/hospitalinspectionsorg
     February 24, 2025 - February 9, 2022 Reducing the Risks of Wrong-Site Surgery: Safety Practices from The

453. The malpractice mess. | PSNet
     psnet.ahrq.gov/issue/malpractice-mess
     November 14, 2018 - June 26, 2019 Death by 1,000 clicks: where electronic health records went wrong.

454. Executive Summary | Digital Healthcare Research
     digital.ahrq.gov/2018-year-review/executive-summary
     January 01, 2018 - Presbyterian Hospital Jason Adelman Having multiple EHRs open simultaneously does not increase wrong-patient … Assess Risk of Wrong Patient Errors in an EMR That Allows Multiple Records Open Research investment

455. Resilient Healthcare and the Safety-I and Safety-II Frameworks | PSNet
     psnet.ahrq.gov/perspective/resilient-healthcare-and-safety-i-and-safety-ii-frameworks
     December 14, 2022 - Defining Safety Traditional views define safety as a state in which as few things as possible go wrong … outlook inverts the Safety-I paradigm and seeks to understand what is going well, as opposed to what went wrong … Safety-I is the approach to understanding something that went wrong by determining why it went wrong. … Safety-I focuses on what went wrong, and how do we stop it from happening.

456. Process Decision Program Chart | Digital Healthcare Research
     digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/process-decision-program-chart
     January 01, 2023 - The questions should revolve around problems that could arise or things that could go wrong.

457. Updates in the Role of Health IT in Patient Safety | PSNet
     psnet.ahrq.gov/perspective/updates-role-health-it-patient-safety
     January 31, 2020 - to these examples, barcode scanning nursing protocols may have the potential to reduce the risk of wrong-patient … that the use of CPOE reduces the overall medication error rate as well as specific error rates for wrong … dose, wrong drug, administration frequency, administration route, and drug-to-drug interaction errors

458. Reducing the Safety Hazards of Monitor Alert and Alarm Fatigue | PSNet
     psnet.ahrq.gov/perspective/reducing-safety-hazards-monitor-alert-and-alarm-fatigue
     May 01, 2016 - seemed logical to build in alarms and alerts to let clinicians know when something is—or might be —wrong … to try to get the attention of the nurse down at the other end of the hall to come and see what was wrong … alarms—we have crisis, warning, advisory, textual—what would really catch your attention that something was wrong … in the unit and everything was quiet—if there were no alarms, no sounds, I would know something was wrong … predictive algorithm about whether you as a patient are stable or going in the right direction or in the wrong

459. Five Steps to Safer Health Care. | PSNet
     psnet.ahrq.gov/issue/five-steps-safer-health-care
     July 21, 2021 - July 21, 2021 Reducing the Risks of Wrong-Site Surgery: Safety Practices from The Joint

460. Joint Commission International Center for Patient Safety. | PSNet
     psnet.ahrq.gov/issue/joint-commission-international-center-patient-safety
     November 27, 2018 - January 1, 2021 Reducing the Risks of Wrong-Site Surgery: Safety Practices from The Joint