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Showing results for "wrong".

81. Computerized Provider Order Entry System | Digital Healthcare Research
    digital.ahrq.gov/technology/computerized-provider-order-entry-system
    January 01, 2023 - 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 … Principal Investigator Lambert, Bruce Project Name Preventing Wrong-Drug and Wrong-Patient

82. Develop and Validate Health IT Safety Measures to Capture Violations of the 5 Rights of Medication Safety – Final Report (pdf file)
    digital.ahrq.gov/sites/default/files/docs/citation/r01hs024538-adelman-final-report-2022.pdf
    January 01, 2022 - , wrong-medication, wrong-route, and wrong-frequency electronic orders, and describe the frequency in … - Reorder measure can be applied to detect wrong-dose, wrong-medication, wrong-route, wrong-frequency … Dose 20,153 23.6 369.0 Wrong Frequency 12,353 14.4 226.2 Wrong Route 5,556 6.5 101.7 Wrong PRN 1,626 … ), Wrong-Dose Pediatrics (age ≤21 years), Wrong-Frequency, Wrong-PRN, and Wrong-Route RAR measures. … near-miss order errors to develop and validate Wrong-Dose, Wrong-Frequency, Wrong-PRN, and Wrong- Route

83. Assessment of incorrect surgical procedures within and outside the operating room. A follow-up study from US Veterans Health Administration medical centers. | PSNet
    psnet.ahrq.gov/issue/assessment-incorrect-surgical-procedures-within-and-outside-operating-room-follow-study-us
    October 24, 2018 - The Joint Commission and National Quality Forum both consider wrong-site, wrong-procedure, and wrong-patient … A WebM&M commentary examined an incident involving a wrong-side surgery. … April 30, 2014 Prevention of wrong-site tooth extraction: clinical guidelines. … September 20, 2011 Operating room briefings and wrong-site surgery. … July 28, 2010 Incidence and root cause analysis of wrong-site pain management procedures

84. Automated Retract-and-Reorder Measures to Improve Medication Safety | Digital Healthcare Research
    digital.ahrq.gov/program-overview/research-stories/automated-retract-and-reorder-measures-improve-medication-safety
    January 01, 2023 - (RAR) Measure to identify wrong-patient electronic orders. … The Wrong-Patient RAR measure enabled systematic and objective identification of wrong-patient orders … These measures identify electronic order errors including wrong dosage, wrong route, wrong frequency, … or wrong medication. … Are there differences in frequency by type of errors, for example, wrong-patient versus wrong-dose errors

85. Deficiencies in Facility Leaders' Response to Critical Surgical Events at the Michael E. DeBakey VA Medical Center in Houston, Texas. | PSNet
    psnet.ahrq.gov/issue/deficiencies-facility-leaders-response-critical-surgical-events-michael-e-debakey-va-medical
    November 29, 2023 - Wrong-site surgery and unintentionally retained surgical items are considered never events . … This report details five wrong-site surgeries and three instances of retained surgical items at one VA … Additionally, the medical center failed to fully report the provider responsible for three of the wrong-site … June 15, 2016 Wrong-site surgery, retained surgical items, and surgical fires: a systematic … 2016 Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site

86. Incorrect surgical procedures within and outside of the operating room. | PSNet
    psnet.ahrq.gov/issue/incorrect-surgical-procedures-within-and-outside-operating-room
    November 21, 2011 - Wrong-patient and wrong-site surgeries are considered never events , as they are devastating errors … December 21, 2014 Preventing wrong site, procedure, and patient events using a common … Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong … Site, Wrong Procedure and Wrong Person Surgery. … November 18, 2009 Wrong site surgery near misses and actual occurrences.

87. Incorrect surgical procedures within and outside of the operating room: a follow-up report. | PSNet
    psnet.ahrq.gov/issue/incorrect-surgical-procedures-within-and-outside-operating-room-follow-report
    April 30, 2014 - procedures in the Veterans Affairs (VA) system found an overall decline in the number of reported wrong-site … , wrong-patient, and wrong-procedure errors compared with the authors' prior study . … April 30, 2014 Preventing wrong site, procedure, and patient events using a common cause … January 4, 2012 Application of human error theory in case analysis of wrong procedures … Site, Wrong Procedure and Wrong Person Surgery.

88. New AHRQ SOPS® Diagnostic Safety Supplemental Items for Medical Offices - Schiff (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/03-new_sops_diagnostic_safety-schiff.pdf
    January 01, 2020 - test, surgery, or treatment 38% You were given wrong or unclear instructions about your follow-up … care 34% You/they were given an incorrect medication, meaning the wrong dose or wrong drug 32% … care instructions 29 Administered the wrong medication dosage 28 Received unnecessary treatment … 27 Providers gave different instructions 24 Got an infection after treatment 24 Doctor gave wrong … diagnosis” • How to even know whether diagnosis was right or wrong?

89. Diagnostic Error Measures: For Quality Improvement & Patient Safety Research (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/adelman-summit2016.pdf
    January 01, 2016 - Wrong Patient Errors Leading to Diagnostic Errors: 1) Order tests on wrong-patient 2) Read results of … wrong-patient 3) Communicate information to the wrong patient. … Wrong Patient Errors Leading to Diagnostic Errors xxVoluntary Reporting Chart Reviews Trigger … JAMA. 2001;285:2114-2120 Wrong-Patient Error Measures Retract-and-Reorder Tool Applied to Complete … on the wrong patient – 1 of 37 admitted patients had an order placed for them that was intended for

90. Using performance improvement to enhance time-out compliance and prevent wrong-site surgery. | PSNet
    psnet.ahrq.gov/issue/using-performance-improvement-enhance-time-out-compliance-and-prevent-wrong-site-surgery
    October 06, 2021 - Commentary Using performance improvement to enhance time-out compliance and prevent wrong-site … Using performance improvement to enhance time-out compliance and prevent wrong-site surgery. … Using performance improvement to enhance time-out compliance and prevent wrong-site surgery. … Prevention February 26, 2025 Patient Safety Primers Wrong-Site … , Wrong-Procedure, and Wrong-Patient Surgery December 15, 2024 Fire safety

91. Adelman, Jason Stuart | Digital Healthcare Research
    digital.ahrq.gov/principal-investigator/adelman-jason-stuart
    July 24, 2024 - Principal Investigator Adelman, Jason Stuart Project Name Assess Risk of Wrong-Patient … Wrong-patient orders in obstetrics. … Association of display of patient photographs in the electronic health record with wrong-patient order … Risk of wrong-patient orders among multiple vs singleton births in the neonatal intensive care units … Principal Investigator Adelman, Jason Stuart Project Name Assess Risk of Wrong-Patient

92. Indication-based prescribing prevents wrong-patient medication errors in computerized provider order entry (CPOE). | Digital Healthcare Research
    digital.ahrq.gov/ahrq-funded-projects/tools-optimizing-medication-safety-top-meds/citation/indication-based
    January 01, 2023 - Indication-based prescribing prevents wrong-patient medication errors in computerized provider order … Indication-based prescribing prevents wrong-patient medication errors in computerized provider order

93. Your diagnosis was wrong. Could doctor bias have been a factor? | PSNet
    psnet.ahrq.gov/issue/your-diagnosis-was-wrong-could-doctor-bias-have-been-factor
    December 22, 2021 - Newspaper/Magazine Article Your diagnosis was wrong. … Citation Text: Your diagnosis was wrong. Could doctor bias have been a factor? Glicksman E. … URL Cite Citation Citation Text: Your diagnosis was wrong … December 2, 2015 When doctors get it wrong: misdiagnoses are getting a closer look.

94. Time Series | Digital Healthcare Research
    digital.ahrq.gov/research-method/time-series
    January 01, 2023 - and Wrong-Patient Errors With Indication Alerts in CPOE Systems - Final Report Citation Lambert … 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 … Effect of number of open charts on intercepted wrong-patient medication orders in an emergency department … Principal Investigator Lambert, Bruce Project Name Preventing Wrong-Drug and Wrong-Patient

95. Association of display of patient photographs in the electronic health record with wrong-patient order entry errors. | Digital Healthcare Research
    digital.ahrq.gov/ahrq-funded-projects/providing-evidence-and-developing-toolkit-accelerate-adoption-patient/citation/association
    January 01, 2023 - Association of display of patient photographs in the electronic health record with wrong-patient order … Association of display of patient photographs in the electronic health record with wrong-patient order

96. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/847733/psn-pdf
    March 16, 2025 - This guidance shares evidence-based steps to address problems such as wrong patient errors and lack … pharmacists-reducing-medication-risk-medical-outpatient-clinics-retrospective-study-18 https://psnet.ahrq.gov/web-mm/medication-errors-retail-pharmacies-wrong-patient-wrong-instructions … https://psnet.ahrq.gov/web-mm/medication-errors-retail-pharmacies-wrong-patient-wrong-instructions

97. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/837594/psn-pdf
    June 29, 2022 - Machine learning models outperform manual result review for the identification of wrong blood in tube … Machine learning models outperform manual result review for the identification of wrong blood in tube … https://psnet.ahrq.gov/issue/machine-learning-models-outperform-manual-result-review-identification- wrong-blood-tube … Wrong blood in tube (WBIT) errors can result in serious diagnostic and treatment errors, but may go … https://psnet.ahrq.gov/issue/machine-learning-models-outperform-manual-result-review-identification-wrong-blood-tube

98. High-risk medications in hospitalized elderly adults: are we making it easy to do the wrong thing? | PSNet
    psnet.ahrq.gov/issue/high-risk-medications-hospitalized-elderly-adults-are-we-making-it-easy-do-wrong-thing
    May 18, 2022 - High-risk medications in hospitalized elderly adults: are we making it easy to do the wrong … High-Risk Medications in Hospitalized Elderly Adults: Are We Making It Easy to Do the Wrong Thing? … High-Risk Medications in Hospitalized Elderly Adults: Are We Making It Easy to Do the Wrong Thing? … May 18, 2022 Evaluating serial strategies for preventing wrong-patient orders in the … March 22, 2017 Risk of wrong-patient orders among multiple vs singleton births in the

99. Risk of wrong-patient orders among multiple vs singleton births in the neonatal intensive care units of 2 integrated health care systems. | Digital Healthcare Research
    digital.ahrq.gov/ahrq-funded-projects/develop-and-validate-health-it-safety-measures-capture-violations-five-rights/citation/risk
    January 01, 2023 - Risk of wrong-patient orders among multiple vs singleton births in the neonatal intensive care units … Risk of wrong-patient orders among multiple vs singleton births in the neonatal intensive care units

100. Blackbox: A Multidisciplinary Team-Based Framework for HIT Error Pattern Detection - Final Report (pdf file)
     digital.ahrq.gov/sites/default/files/docs/citation/r21hs024755-hettinger-final-report-2019.pdf
     January 01, 2019 - Cases of interest across five error types (including wrong route, wrong weight and wrong dose among … Each of the error types (Wrong Route, Wrong Weight, etc.) will be explored in greater detail below. … the wrong route. … Wrong Side Wrong sided surgeries are a never event in modern healthcare yet they continue to happen … Order written for wrong patient and then voided with reason "wrong patient/wrong encounter".