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Showing results for "failure".

121. Communication failure: analysis of prescribers' use of an internal free-text field on electronic prescriptions. | PSNet
     psnet.ahrq.gov/issue/communication-failure-analysis-prescribers-use-internal-free-text-field-electronic
     May 20, 2019 - Study Communication failure: analysis of prescribers' use of an internal free-text … Communication failure: analysis of prescribers’ use of an internal free-text field on electronic prescriptions … More than 10% of medication orders exhibited a communication failure between prescriber and pharmacist … Communication failure: analysis of prescribers’ use of an internal free-text field on electronic prescriptions

122. The role of automation in complex system failures. | PSNet
     psnet.ahrq.gov/issue/role-automation-complex-system-failures
     June 28, 2013 - The authors present a case of automation failure and discuss the role human practitioners played in recovering … from the failure.

123. Failure mode and effects analysis: a useful tool for risk identification and injury prevention. | PSNet
     psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-useful-tool-risk-identification-and-injury-prevention
     September 24, 2010 - Commentary Failure mode and effects analysis: a useful tool for risk identification … Failure mode and effects analysis: a useful tool for risk identification and injury prevention. … discusses the importance of proactive risk assessment and provides insights on the successful use of failure … Failure mode and effects analysis: a useful tool for risk identification and injury prevention. … May 18, 2011 Failure mode and effect analysis: a technique to prevent chemotherapy errors

124. Exploratory analyses of the "failure to rescue" measure: evaluation through medical record review. | PSNet
     psnet.ahrq.gov/issue/exploratory-analyses-failure-rescue-measure-evaluation-through-medical-record-review
     December 15, 2008 - Study Exploratory analyses of the "failure to rescue" measure: evaluation through … Exploratory analyses of the "failure to rescue" measure: evaluation through medical record review. … The limitations of the failure to rescue measurement at identifying systemic problems in care delivery … Exploratory analyses of the "failure to rescue" measure: evaluation through medical record review. … July 12, 2010 View More Related Resources Failure to rescue as

125. Key performance outcomes of patient safety curricula: root cause analysis, failure mode and effects analysis, and structured communications skills. | PSNet
     psnet.ahrq.gov/issue/key-performance-outcomes-patient-safety-curricula-root-cause-analysis-failure-mode-and
     July 23, 2010 - Commentary Key performance outcomes of patient safety curricula: root cause analysis, failure … Key performance outcomes of patient safety curricula: root cause analysis, failure mode and effects analysis … This commentary recommends that courses covering root cause analysis , failure mode and effects analysis … Key performance outcomes of patient safety curricula: root cause analysis, failure mode and effects analysis … See More About The Topic Pharmacists Educators Pharmacy Root Cause Analysis Failure

126. Health care failure mode and effect analysis to reduce NICU line–associated bloodstream infections. | PSNet
     psnet.ahrq.gov/issue/health-care-failure-mode-and-effect-analysis-reduce-nicu-line-associated-bloodstream
     April 24, 2018 - Study Health care failure mode and effect analysis to reduce NICU line–associated … Health care failure mode and effect analysis to reduce NICU line-associated bloodstream infections. … Successful application of a failure mode and effect analysis approach resulted in a marked reduction … Health care failure mode and effect analysis to reduce NICU line-associated bloodstream infections. … October 13, 2010 Random safety auditing, root cause analysis, failure mode and effects

127. Managing clinical failure: a complex adaptive system perspective. | PSNet
     psnet.ahrq.gov/issue/managing-clinical-failure-complex-adaptive-system-perspective
     August 13, 2014 - Study Managing clinical failure: a complex adaptive system perspective. … Managing clinical failure: a complex adaptive system perspective. … Managing clinical failure: a complex adaptive system perspective.

128. Forgive and Remember: Managing Medical Failure. 2nd ed. | PSNet
     psnet.ahrq.gov/issue/forgive-and-remember-managing-medical-failure-2nd-ed
     March 27, 2005 - Report Classic Forgive and Remember: Managing Medical Failure … Citation Text: Forgive and Remember: Managing Medical Failure. 2nd ed. … Cite Citation Citation Text: Forgive and Remember: Managing Medical Failure … November 18, 2015 Failure in Safety-Critical Systems: A Handbook of Accident and Incident

129. Failure to administer recommended chemotherapy: acceptable variation or cancer care quality blind spot? | PSNet
     psnet.ahrq.gov/issue/failure-administer-recommended-chemotherapy-acceptable-variation-or-cancer-care-quality-blind
     September 02, 2020 - Study Failure to administer recommended chemotherapy: acceptable variation or cancer … Failure to administer recommended chemotherapy: acceptable variation or cancer care quality blind spot … The authors conclude that failure to administer chemotherapy is a significant safety gap that should … Failure to administer recommended chemotherapy: acceptable variation or cancer care quality blind spot

130. Prospective risk analysis of health care processes: a systematic evaluation of the use of HFMEA in Dutch health care. | PSNet
     psnet.ahrq.gov/issue/prospective-risk-analysis-health-care-processes-systematic-evaluation-use-hfmea-dutch-health
     March 10, 2010 - This study analyzed 13 failure mode and effect analysis (FMEA) efforts to understand how to improve … January 13, 2021 Application of failure mode effect analysis to improve the care of septic … June 14, 2017 Using Health Care Failure Mode and Effect Analysis: the VA National Center … March 28, 2011 Failure mode and effects analysis: an empirical comparison of failure … December 15, 2010 Using failure mode and effects analysis to plan implementation of smart

131. Patient safety in complementary medicine through the application of clinical risk management in the public health system. | PSNet
     psnet.ahrq.gov/issue/patient-safety-complementary-medicine-through-application-clinical-risk-management-public
     February 15, 2023 - Failure mode and effect analysis is a process used to prospectively identify error risk within a particular … This study describes the application of failure mode and effect analysis to better understand the patient … 2020 Patient involvement in evaluation of safety in oral antineoplastic treatment: a failure … January 31, 2018 A review of healthcare failure mode and effects analysis (HFMEA) in … January 16, 2013 Using Healthcare Failure Mode and Effect Analysis to reduce medication

132. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867383/psn-pdf
     December 18, 2024 - Interactions between the context of a health-care organisation and failure: the situational impact of … failure on organisational learning. … failure on organisational learning. … https://psnet.ahrq.gov/issue/interactions-between-context-health-care-organisation-and-failure-situational-impact-failure … https://psnet.ahrq.gov/issue/interactions-between-context-health-care-organisation-and-failure-situational-impact-failure

133. Systematically Identified Failure Is the Route to a Successful Health System. | PSNet
     psnet.ahrq.gov/issue/systematically-identified-failure-route-successful-health-system
     January 10, 2018 - Special or Theme Issue Systematically Identified Failure Is the Route to a Successful … Citation Text: Systematically Identified Failure Is the Route to a Successful Health System. … Exploring challenges to system-level efforts to learn from failure in health care, articles in this … Cite Citation Citation Text: Systematically Identified Failure

134. Situational Awareness | PSNet
     psnet.ahrq.gov/taxonomy/term/3440
     April 10, 2025 - Failure to maintain situational awareness can result in various problems that compound the crisis. … point that steps are not taken to address immediately life-threatening problems such as respiratory failure … may ignore signals from a team member, which may result in escalating anxiety for the team member, failure

135. Failure mode and effects analysis application to critical care medicine. | PSNet
     psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-application-critical-care-medicine
     June 10, 2013 - Review Failure mode and effects analysis application to critical care medicine. … Failure mode and effects analysis application to critical care medicine. … This article provides background on failure mode and effects analysis (FMEA) and reviews both the positive … Failure mode and effects analysis application to critical care medicine.

136. Effect of cognitive aids on adherence to best practice in the treatment of deteriorating surgical patients: a randomized clinical trial in a simulation setting. | PSNet
     psnet.ahrq.gov/issue/effect-cognitive-aids-adherence-best-practice-treatment-deteriorating-surgical-patients
     September 30, 2020 - Failure to rescue  is a significant cause of morbidity and mortality and is often associated with human … Use of cognitive aids significantly reduced omitted critical management steps and failure to adhere to … WebM&M Cases Hemorrhagic Shock after Elective Spine Surgery: Failure … January 18, 2023 Failure to rescue following emergency surgery: a FRAM analysis of the … August 20, 2018 Failure events in transition of care for surgical patients.

137. FMEA team performance in health care: a qualitative analysis of team member perceptions. | PSNet
     psnet.ahrq.gov/issue/fmea-team-performance-health-care-qualitative-analysis-team-member-perceptions
     December 31, 2014 - Failure mode and effect analysis (FMEA), a tool that allows prospective risk assessment, has been … December 18, 2013 Using failure mode and effects analysis to plan implementation of smart … February 19, 2020 View More Related Resources Using failure mode … June 27, 2011 Failure mode and effects analysis: an empirical comparison of failure mode … December 15, 2010 Is failure mode and effect analysis reliable?

138. Risks and medication errors analysis to evaluate the impact of a chemotherapy compounding workflow management system on cancer patients' safety. | PSNet
     psnet.ahrq.gov/issue/risks-and-medication-errors-analysis-evaluate-impact-chemotherapy-compounding-workflow
     January 27, 2019 - This study applied failure mode, effect, and criticality analysis   (FMECA) methodology to identify … January 12, 2022 View More Related Resources Using failure mode … February 20, 2019 Using Failure Mode and Effects Analysis for safe administration of … May 27, 2011 Health Care Failure Mode and Effect Analysis: a useful proactive risk analysis … March 28, 2011 Failure mode and effects analysis: an empirical comparison of failure

139. The quality of hospital work environments and missed nursing care is linked to heart failure readmissions: a cross-sectional study of US hospitals. | PSNet
     psnet.ahrq.gov/issue/quality-hospital-work-environments-and-missed-nursing-care-linked-heart-failure-readmissions
     September 09, 2020 - The quality of hospital work environments and missed nursing care is linked to heart failure … The quality of hospital work environments and missed nursing care is linked to heart failure readmissions … nurses' work environment and more frequent reports of missed care also had higher readmissions for heart failure … The quality of hospital work environments and missed nursing care is linked to heart failure readmissions

140. Error traps in pediatric patient blood management in the perioperative period. | PSNet
     psnet.ahrq.gov/issue/error-traps-pediatric-patient-blood-management-perioperative-period
     January 12, 2022 - This article highlights five patient safety risks during pediatric perioperative blood management (failure … to recognize and treat preoperative anemia, failure to obtain informed consent regarding perioperative … blood management, failure to consider specific intraoperative blood conservation techniques in children … , failure to recognize massive hemorrhage, failure to prevent unnecessary transfusion ).