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Total Results: 5,540 records

Showing results for "wrong".

  1. A towel with a safety message. | PSNet

    psnet.ahrq.gov/issue/towel-safety-message
    October 24, 2012 - July 20, 2011 The pain of wrong site surgery. … July 6, 2011 Wrong body part, wrong patient surgeries continue despite new procedures … June 8, 2011 The wrong foot, and other tales of surgical error. … March 4, 2009 Most surgery in wrong spot done on spine: 11 such cases found in state

  2. Case outcomes in a communication-and-resolution program in New York hospitals. | PSNet

    psnet.ahrq.gov/issue/case-outcomes-communication-and-resolution-program-new-york-hospitals
    February 05, 2014 - March 18, 2020 Electronic patient identification for sample labeling reduces wrong blood … May 26, 2011 Experience of wrong site surgery and surgical marking practices among clinicians … December 17, 2008 Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events

  3. Surgical specimen identification errors: a new measure of quality in surgical care. | PSNet

    psnet.ahrq.gov/issue/surgical-specimen-identification-errors-new-measure-quality-surgical-care
    June 16, 2011 - January 2, 2017 Operating room briefings and wrong-site surgery. … November 26, 2008 Achieving the National Quality Forum's "Never Events": prevention of wrong … site, wrong procedure, and wrong patient operations. … February 26, 2020 WebM&M Cases “This is the wrong … : Evaluating a Near-Miss Wrong Transfusion Event January 29, 2020 Error Reduction

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49435/psn-pdf
    February 01, 2004 - site, wrong person, and wrong procedure surgery. … In a recent study looking at the incidence of wrong site surgery among hand surgeons, 21% (217/1050) … 6,700,000 surgical procedures, 242 were performed at the wrong site, making this a "rare occurrence … In our large (approximately 600 beds), urban teaching hospital, we have seen two wrong side invasive … Incidence of wrong-site surgery among hand surgeons.

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40254/psn-pdf
    September 19, 2016 - An AHRQ WebM&M commentary discusses the effect of committing a wrong-site procedure error on a resident … caring-our-own-deploying-systemwide-second-victim-rapid-response-team https://psnet.ahrq.gov/web-mm/how-do-providers-recover-errors https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45225/psn-pdf
    June 15, 2016 - This case analysis discusses a wrong-patient transfusion error in a hospital's emergency room and reviews … perspective/organizational-change-face-highly-public-errors-ii-duke-experience https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery

  7. Patient Mix-Up | PSNet

    psnet.ahrq.gov/web-mm/patient-mix
    December 01, 2007 - She was about to administer the haloperidol to the wrong Mr. … Moreover, the error of commission—administering the wrong drug to Joe Smith—would in this case likely … Error Ordering Order written in the wrong chart (or entered into the wrong computerized … record) Transcription Order written in correct chart, but order sheets have the wrong … name stamp Transcription Order correctly written, but transcribed to wrong Medication

  8. What pilots can teach hospitals about patient safety. | PSNet

    psnet.ahrq.gov/issue/what-pilots-can-teach-hospitals-about-patient-safety
    May 22, 2009 - October 27, 2021 Emergency departments are higher-risk locations for wrong blood in tube … January 25, 2010 Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49512/psn-pdf
    May 01, 2006 - Neither should operating on the wrong side of the right patient. … JCAHO has recommended a series of steps to prevent wrong-site, wrong-side, and wrong-person procedures … To strengthen defenses against wrong-site and wrong-patient invasive procedures, hospitals should implement … Sentinel Event Alert: A follow-up review of wrong site surgery. … Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery.

  10. Deviation from a preoperative surgical and anaesthetic care plan is associated with increased risk of adverse intraoperative events in major abdominal surgery. | PSNet

    psnet.ahrq.gov/issue/deviation-preoperative-surgical-and-anaesthetic-care-plan-associated-increased-risk-adverse
    August 20, 2018 - Study A standardized marking procedure for ENT operations to prevent wrong-site … April 17, 2013 Application of human error theory in case analysis of wrong procedures … 2011 Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site … Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong … Site, Wrong Procedure and Wrong Person Surgery.

  11. Spotlight Case [MONTH] 2003 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.76_slideshow.ppt
    October 01, 2004 - both in engineered safety devices and in human procedures Review strategies to prevent delivery of wrong … oxygen and air meters both fit the same adapters, meaning that it is easily possible to connect the wrong … What Went Wrong in This Case Tubing connected to green Christmas tree adapter which was inadvertently … Engineered Safety Devices Engineered Safety Device: a physical arrangement that precludes the wrong … Take-Home Points Consider strategies to reduce the likelihood of connecting oxygen tubing to the wrong

  12. Spotlight Case July 2008 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.299_slideshow.ppt
    May 01, 2013 - Spotlight Case July 2008 Spotlight Case Right Regimen, Wrong Cancer: Patient Catches Medical Error … * * Case: Right Regimen, Wrong Cancer (2) In the morning his bedside nurse for the day came in … * * Case: Right Regimen, Wrong Cancer (3) Rather than the 3-day regimen for metastatic penile … own care and able to identify and intercept errors before they occur * * Case: Right Regimen, Wrong … In choosing the chemotherapy regimen, the oncology fellow inadvertently chose the wrong paper order set—he

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41355/psn-pdf
    April 05, 2013 - health care–associated infections, adverse drug events, retained foreign bodies after surgery, and wrong-site … comparative-economic-analyses-patient-safety-improvement-strategies-acute-care-systematic https://psnet.ahrq.gov/primer/health-care-associated-infections https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36907/psn-pdf
    September 14, 2012 - The 2011 update now consists of 29 events, organized into surgical events (e.g., wrong-site surgery) … serious-reportable-events-healthcare-2011-update https://psnet.ahrq.gov/primer/never-events https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41097/psn-pdf
    January 25, 2012 - What if the doctor is wrong? January 25, 2012 Landro L. … https://psnet.ahrq.gov/issue/what-if-doctor-wrong This newspaper article discusses second opinions as … https://psnet.ahrq.gov/issue/what-if-doctor-wrong https://psnet.ahrq.gov/primer/diagnostic-errors

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36714/psn-pdf
    August 05, 2008 - How two rights can make a wrong. August 5, 2008 Markel H. … https://psnet.ahrq.gov/issue/how-two-rights-can-make-wrong This article discusses the problems associated … https://psnet.ahrq.gov/issue/how-two-rights-can-make-wrong

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36625/psn-pdf
    November 21, 2016 - When Things Go Wrong: Voices of Patients and Families. … 21, 2016 CRICO/RMF; Harvard Risk Management Foundation https://psnet.ahrq.gov/issue/when-things-go-wrong-voices-patients-and-families … https://psnet.ahrq.gov/issue/when-things-go-wrong-voices-patients-and-families

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38953/psn-pdf
    September 16, 2009 - When patient handoffs go terribly wrong. September 16, 2009 Chen PW. … https://psnet.ahrq.gov/issue/when-patient-handoffs-go-terribly-wrong Relating a story of a handoff mistake … https://psnet.ahrq.gov/issue/when-patient-handoffs-go-terribly-wrong https://psnet.ahrq.gov/primer/handoffs-and-signouts

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33652/psn-pdf
    June 01, 2007 - Analysis of wrong-patient/wrong-site surgical errors led to development of the New York preoperative … body part Surgery performed on the wrong patient Wrong surgical procedure performed on a patient … Patient death or serious disability associated with a medication error (e.g., errors involving the wrong … drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration … donor sperm or wrong egg Environmental Events Patient death or serious disability associated with

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35295/psn-pdf
    July 24, 2008 - Buying the wrong medicine overseas.  July 24, 2008 Chase M.The Wall Street Journal. … Aug 2005 https://psnet.ahrq.gov/issue/buying-wrong-medicine-overseas This article reports that in other … https://psnet.ahrq.gov/issue/buying-wrong-medicine-overseas
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