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Showing results for "wrong".

61. A standardized marking procedure for ENT operations to prevent wrong-site surgery: development, establishment and subsequent evaluation among patients and medical personnel. | PSNet
    psnet.ahrq.gov/innovation/standardized-marking-procedure-ent-operations-prevent-wrong-site-surgery-development
    February 01, 2013 - EMERGING INNOVATIONS A standardized marking procedure for ENT operations to prevent wrong-site surgery … A standardized marking procedure for ENT operations to prevent wrong-site surgery: development, establishment … Although wrong-site surgeries are rare , the consequences can be very serious . … April 19, 2023 Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient … June 15, 2011 Wrong-site sinus surgery in otolaryngology.

62. Electronic patient identification for sample labeling reduces wrong blood in tube errors. | PSNet
    psnet.ahrq.gov/issue/electronic-patient-identification-sample-labeling-reduces-wrong-blood-tube-errors
    September 20, 2012 - Emerging Classic Electronic patient identification for sample labeling reduces wrong … Electronic patient identification for sample labeling reduces wrong blood in tube errors. … Wrong-patient errors in blood transfusion can lead to serious patient harm. … This pre–post study examined the impact of barcode labeling on the rate of wrong blood in tube errors … Electronic patient identification for sample labeling reduces wrong blood in tube errors.

63. A multistep approach to improving biopsy site identification in dermatology: physician, staff, and patient roles based on a Delphi consensus. | PSNet
    psnet.ahrq.gov/issue/multistep-approach-improving-biopsy-site-identification-dermatology-physician-staff-and
    October 12, 2022 - March 19, 2019 View More Related Resources Insurance claims for wrong-side … , wrong-organ, wrong-procedure, or wrong-person surgical errors: a retrospective study for 10 years. … January 17, 2019 Using "near misses" analysis to prevent wrong-site surgery. … Other Cheek March 1, 2012 Outcome of 6 years of protocol use for preventing wrong … October 4, 2011 Wrong-patient, wrong-site procedures persist despite safety protocol.

64. Machine learning models outperform manual result review for the identification of wrong blood in tube errors in complete blood count results. | PSNet
    psnet.ahrq.gov/issue/machine-learning-models-outperform-manual-result-review-identification-wrong-blood-tube
    May 13, 2020 - Machine learning models outperform manual result review for the identification of wrong … Machine learning models outperform manual result review for the identification of wrong blood in tube … Wrong blood in tube (WBIT) errors can result in serious diagnostic and treatment errors, but may go … Machine learning models outperform manual result review for the identification of wrong blood in tube … July 5, 2023 Adding automation and independent dual verification to reduce wrong blood

65. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/33576/psn-pdf
    December 15, 2024 - Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery December 15, 2024 Wrong-Site, Wrong-Procedure … https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery PSNet primers are … These "wrong-site, wrong-procedure, wrong-patient errors" (WSPEs) are rightly termed never events—errors … Preventing Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery Early efforts to prevent WSPEs focused … Current Context Wrong-patient, wrong-site, and wrong-procedure errors are all considered never events

66. Effect of number of open charts on intercepted wrong-patient medication orders in an emergency department. | Digital Healthcare Research
    digital.ahrq.gov/ahrq-funded-projects/assess-risk-wrong-patient-errors-emr-allows-multiple-records-open/citation/assess
    January 01, 2023 - Effect of number of open charts on intercepted wrong-patient medication orders in an emergency department … Effect of number of open charts on intercepted wrong-patient medication orders in an emergency department … 29025090 Principal Investigator Adelman, Jason Stuart Project Name Assess Risk of Wrong-Patient

67. Foundational Terminology for Diagnosis Relating to Suboptimal Processes and Outcomes | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-terminology7.html
    April 01, 2025 - Investigators attempted to create a meaningful taxonomy clarifying what was lacking or wrong. … Diagnostic Failure A failed process or a wrong or delayed diagnosis. … For example, a diagnosis of pneumothorax might be a wrong label (misdiagnosis) if the actual problem … Similar to the term wrong diagnosis or incorrect diagnosis . 30 Missed Diagnosis A condition that … . 3 In general, medical adverse events tend to be (but are not always) errors of commission (e.g., wrong

68. Assess Risk of Wrong Patient Errors in an EMR That Allows Multiple Records Open - Final Report | Digital Healthcare Research
    digital.ahrq.gov/ahrq-funded-projects/assess-risk-wrong-patient-errors-emr-allows-multiple-records-open/final-report
    January 01, 2023 - Assess Risk of Wrong Patient Errors in an EMR That Allows Multiple Records Open - Final Report … Assess Risk of Wrong Patient Errors in an EMR That Allows Multiple Records Open - Final Report. … Principal Investigator Adelman, Jason Stuart Project Name Assess Risk of Wrong-Patient

69. The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment | PSNet
    psnet.ahrq.gov/web-mm/wrong-blade-lack-familiarity-pediatric-emergency-equipment
    June 01, 2018 - The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment Citation Text: … The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment. PSNet [internet]. … The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment. PSNet [internet]. … The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment. PSNet [internet].

70. Descriptive analysis of patient misidentification from incident report system data in a large academic hospital federation. | PSNet
    psnet.ahrq.gov/issue/descriptive-analysis-patient-misidentification-incident-report-system-data-large-academic
    August 24, 2022 - Of the 293 reported incidents, the most common errors were missing wristbands , wrong charts or notes … in files, administrative issues, and wrong labeling. … March 29, 2023 Adding automation and independent dual verification to reduce wrong blood … : Evaluating a Near-Miss Wrong Transfusion Event January 29, 2020 … May 29, 2019 Wrong-patient blood transfusion error: leveraging technology to overcome

71. The Other Side | PSNet
    psnet.ahrq.gov/web-mm/other-side
    May 01, 2007 - Understand the key components of the Universal Protocol for eliminating wrong site, wrong procedure, … wrong person surgery. … Recently, JCAHO released a Universal Protocol for preventing wrong person, wrong procedure, and wrong … Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. [ go to related … Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. [ go to related

72. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/33561/psn-pdf
    September 15, 2024 - site Surgery or other invasive procedure performed on the wrong patient Wrong surgical or other invasive … drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration … https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events https://psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event … https://psnet.ahrq.gov/issue/medicare-says-it-wont-cover-hospital-errors https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery … https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery https://psnet.ahrq.gov

73. Preventing wrong site, procedure, and patient events using a common cause analysis. | PSNet
    psnet.ahrq.gov/issue/preventing-wrong-site-procedure-and-patient-events-using-common-cause-analysis
    October 03, 2017 - Study Preventing wrong site, procedure, and patient events using a common cause analysis … Preventing wrong site, procedure, and patient events using a common cause analysis. … Preventing wrong site, procedure, and patient events using a common cause analysis. … June 27, 2018 Wrong-site and wrong-patient procedures in the Universal Protocol era: … Site, Wrong Procedure and Wrong Person Surgery.

74. Develop and Validate Health IT Safety Measures To Capture Violations of the Five Rights of Medication Safety | Digital Healthcare Research
    digital.ahrq.gov/ahrq-funded-projects/develop-and-validate-health-it-safety-measures-capture-violations-five-rights
    January 01, 2023 - , wrong-medication, wrong-route, and wrong-frequency electronic orders in an acute care setting, by extending … Conduct a multisite observational study describing the overall frequency of wrong-patient, wrong-dose … , wrong-medication, wrong-route, and wrong-frequency electronic orders, and describe the frequency in … These measures identify electronic order errors including wrong dosage, wrong route, wrong frequency, … or wrong medication.

75. Lambert, Bruce | Digital Healthcare Research
    digital.ahrq.gov/principal-investigator/lambert-bruce
    January 01, 2023 - Lambert, Bruce Preventing Wrong-Drug and Wrong-Patient Errors With Indication … Preventing Wrong-Drug and Wrong-Patient Errors With Indication Alerts in CPOE Systems – Final Report. … Principal Investigator Lambert, Bruce Project Name Preventing Wrong-Drug and Wrong-Patient … Principal Investigator Lambert, Bruce Project Name Preventing Wrong-Drug and Wrong-Patient … Principal Investigator Lambert, Bruce Project Name Preventing Wrong-Drug and Wrong-Patient

76. Diagnostic Error in the Testing Process | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-dx-stewardship4.html
    August 01, 2024 - Challenges Ahead Conclusion References Diagnostic errors include missed, delayed, and wrong … ordering urine cultures in patients without urinary tract symptoms, which can increase the risk of wrong … specimen mishandling; for instance, contamination of specimens at the time of collection can result in wrong

77. Common general surgical never events: analysis of NHS England never event data. | PSNet
    psnet.ahrq.gov/issue/common-general-surgical-never-events-analysis-nhs-england-never-event-data
    April 14, 2021 - 2020 in the National Health Service (NHS) England and categorized them into three main categories: wrong-site … surgery (53.58%), retained items post-procedure (44.54%), and wrong implant/prosthesis (1.88%). … More Related Resources Patient Safety Primers Wrong-Site … , Wrong-Procedure, and Wrong-Patient Surgery December 15, 2024 … 2013 Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site

78. Medication Without Harm: How Digital Healthcare Tools Can Support Providers and Improve Patient Safety (pdf file)
    digital.ahrq.gov/sites/default/files/docs/medication-without-harm-slides-07242024.pdf
    January 12, 2025 - Wrong-Patient Error in 1820 63 Cause of Wrong-Patient Errors 64 Wrong Patient Retract-and-Reorder … Wrong-Patient Orders, by Order Wrong-Patient Orders, by Patient Wrong-Patient Orders, by Set Total … Dose 20,153 Wrong Frequency 12,353 Wrong Route 5,556 Wrong PRN 1,626 Wrong Duration 418 Other/Unknown … New RAR measures identify wrong dose, wrong frequency, and wrong route medication errors. … X Wrong-Patient Error in 1820 Cause of Wrong-Patient Errors Wrong Patient Retract-and-Reorder (WP-RAR

79. X-ray Flip | PSNet
    psnet.ahrq.gov/web-mm/x-ray-flip
    August 10, 2019 - 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) … of physicians reported having performed wrong site surgery at least once in their career.( 5 ) Of an … In our large (approximately 600 beds), urban teaching hospital, we have seen two wrong side invasive … Incidence of wrong-site surgery among hand surgeons.

80. Large-scale observational study of AI-based patient and surgical material verification system in ophthalmology: real-world evaluation in 37 529 cases. | PSNet
    psnet.ahrq.gov/issue/large-scale-observational-study-ai-based-patient-and-surgical-material-verification-system
    August 27, 2012 - Wrong-side and wrong-patient surgical errors can have devastating consequences. … More Related Resources Patient Safety Primers Wrong-Site … , Wrong-Procedure, and Wrong-Patient Surgery December 15, 2024 Grading recommendations … November 15, 2023 Insurance claims for wrong-side, wrong-organ, wrong-procedure, or wrong-person