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Total Results: 7,832 records

Showing results for "failure".

1361. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46943/psn-pdf
      November 16, 2018 - piece-my-mind-art-constructive-worrying Both organizational culture and individual accountability are key to admitting and learning from failure … piece-my-mind-art-constructive-worrying https://psnet.ahrq.gov/primer/culture-safety https://psnet.ahrq.gov/issue/strategies-learning-failure

1362. Acute Respiratory Arrest in Pregnancy | PSNet
      psnet.ahrq.gov/web-mm/acute-respiratory-arrest-pregnancy
      August 15, 2018 - rupture of membranes ( Figure ).( 1,2 ) As seen in this case, common errors in management include failure … shortness of breath and exacerbation in maternal BPs despite the use of antihypertensive medication, failure … to obtain the appropriate laboratory tests, and failure to hospitalize for close monitoring and timely … with twins was at very high risk for development of superimposed preeclampsia and congestive heart failure … of this visit, the patient should have been hospitalized for evaluation of possible congestive heart failure

1363. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49545/psn-pdf
      September 01, 2007 - Coming Undone: Failure of Closure Device September 1, 2007 Baez-Escudero JL, Levine GN. … Coming Undone: Failure of Closure Device. PSNet [internet]. 2007. … https://psnet.ahrq.gov/web-mm/coming-undone-failure-closure-device The Case A 65-year-old man underwent … patient, given the delay in the development of the hematoma, the likely cause of the bleeding was failure … Retroperitoneal hematomas can result from improper arterial puncture or failure to achieve adequate

1364. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47462/psn-pdf
      October 31, 2018 - emergency-department-checklist-innovation-improve-safety-emergency-care Enhancing information systems and team communication can reduce failure-to-rescue … emergency-department-checklist-innovation-improve-safety-emergency-care https://psnet.ahrq.gov/primer/failure-rescue

1365. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41763/psn-pdf
      October 10, 2012 - latency-ecg-displays-hospital-telemetry-systems-science-advisory-american-heart-association https://psnet.ahrq.gov/issue/alarm-interventions-during-medical-telemetry-monitoring-failure-mode-effects-analysis … https://psnet.ahrq.gov/issue/alarm-interventions-during-medical-telemetry-monitoring-failure-mode-effects-analysis

1366. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38727/psn-pdf
      November 25, 2009 - psnet.ahrq.gov/issue/fmea-team-performance-health-care-qualitative-analysis-team-member- perceptions Failure … https://psnet.ahrq.gov/issue/basics-fmea-2nd-edition https://psnet.ahrq.gov/issue/using-health-care-failure-mode-and-effect-analysis-va-national-center-patient-safetys

1367. Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication. | PSNet
      psnet.ahrq.gov/issue/evaluation-preoperative-checklist-and-team-briefing-among-surgeons-nurses-and
      August 28, 2013 - Using trainee failures to enhance learning: a qualitative study of pediatric hospitalists on allowing failure … 'Whatever you cut, I can fix it': clinical supervisors' interview accounts of allowing trainee failure … November 21, 2018 Allowing failure for educational purposes in postgraduate clinical

1368. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43158/psn-pdf
      May 07, 2014 - rates of cardiac arrests or intensive care unit transfers, this study advocates for using the AHRQ failure … Failure to rescue rates declined in the second year after implementation of the rapid response team

1369. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45028/psn-pdf
      May 25, 2016 - approaches should address to build trust for blame-free response to error and enable learning from failure … psnet.ahrq.gov/perspective/accountability-patient-safety https://psnet.ahrq.gov/issue/strategies-learning-failure

1370. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43692/psn-pdf
      April 22, 2015 - found that most perioperative deaths were not due to surgical error and advocates for focusing on failure … The authors believe that emphasizing failure to rescue can promote a systems approach to reduce surgical

1371. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39618/psn-pdf
      August 03, 2010 - This study found that preventable delays in lung cancer diagnosis were largely attributable to either failure … in recognizing documented abnormal imaging results or failure to complete diagnostic procedures in

1372. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.45_slideshow.ppt
      January 01, 2004 - Vasovagal 6.5 Congestive heart failure 5 Hyperventilation 3.3 Hypertensive crisis 2.2 Chest wall … -57 Diastolic murmur 28% 21-36 Pulse deficit 31% 24-39 Pericardial rub 6% 3-13 Congestive heart failure … Diastolic murmur 28% 21-36 Pulse deficit 31% 24-39 Pericardial rub 6% 3-13 Congestive heart failure … Vasovagal 6.5 Congestive heart failure 5 Hyperventilation 3.3 Hypertensive crisis 2.2 Chest wall … Vasovagal 6.5 Congestive heart failure 5 Hyperventilation 3.3 Hypertensive crisis 2.2 Chest wall

1373. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38779/psn-pdf
      July 15, 2009 - prospective-risk-analysis-health-care-processes-systematic-evaluation-use- hfmea-dutch-health This study analyzed 13 failure … https://psnet.ahrq.gov//#failuremodeandeffectanalysis https://psnet.ahrq.gov/issue/using-health-care-failure-mode-and-effect-analysis-va-national-center-patient-safetys

1374. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47068/psn-pdf
      June 25, 2018 - https://psnet.ahrq.gov/issue/need-closed-loop-systems-management-abnormal-test-results Failure to follow … psnet.ahrq.gov/issue/need-closed-loop-systems-management-abnormal-test-results https://psnet.ahrq.gov/issue/failure-follow-test-results-ambulatory-patients-systematic-review

1375. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45341/psn-pdf
      July 27, 2016 - rapid response teams and early warning systems to help prevent these situations from resulting in failure … psnet.ahrq.gov/issue/how-avoid-catastrophic-events-ward https://psnet.ahrq.gov/issue/escalation-care-and-failure-rescue-multicenter-multiprofessional-qualitative-study

1376. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41541/psn-pdf
      September 26, 2012 - failures-communication-and-information-transfer-across-surgical-care-pathway-interview-study https://psnet.ahrq.gov/issue/communication-failure-operating-room

1377. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40068/psn-pdf
      January 19, 2011 - application-root-cause-analysis-malpractice-claim-files-related-diagnostic- failures This study applied root cause analysis to cases of diagnostic failure

1378. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34794/psn-pdf
      November 18, 2015 - accident-analysis-large-scale-technological-disasters-applied-anaesthetic-complication https://psnet.ahrq.gov/glossary/active-error-or-active-failure

1379. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44179/psn-pdf
      November 20, 2015 - routine-failures-process-blood-testing-and-communication-results-patients-primary-care-uk https://psnet.ahrq.gov/issue/frequency-failure-inform-patients-clinically-significant-outpatient-test-results

1380. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37873/psn-pdf
      June 16, 2009 - from lack of a standardized signout process to environmental factors (such as ED overcrowding) and failure