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Total Results: 7,831 records

Showing results for "failure".

1381. 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

1382. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41745/psn-pdf
      October 10, 2012 - Although direct communication of results to patients via email has been proposed as a strategy to prevent failure … email-communicating-results-diagnostic-medical-investigations-patients https://psnet.ahrq.gov/issue/failure-follow-test-results-ambulatory-patients-systematic-review

1383. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43912/psn-pdf
      February 25, 2015 - https://psnet.ahrq.gov/issue/patient-safety-dialysis-access Patients with chronic kidney failure are … safety in end-stage renal disease care, explores factors specific to this setting that contribute to failure

1384. 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

1385. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45724/psn-pdf
      July 21, 2017 - This commentary discusses learning from failure, or remembrance, in health care and suggests avenues … heart-darkness-impact-perceived-mistakes-physicians https://psnet.ahrq.gov/issue/not-again https://psnet.ahrq.gov/issue/strategies-learning-failure

1386. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34782/psn-pdf
      November 01, 2016 - psnet.ahrq.gov/issue/when-systems-fail This review provides a detailed account of managerial causes of failure … and managerial failure prevention strategies.

1387. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44152/psn-pdf
      November 06, 2015 - human-factors-engineering-its-place-and-potential-or-safety https://psnet.ahrq.gov/issue/applicability-healthcare-failure-mode-and-effects-analysis-healthcare-epidemiology-evaluation … https://psnet.ahrq.gov/issue/applicability-healthcare-failure-mode-and-effects-analysis-healthcare-epidemiology-evaluation

1388. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49675/psn-pdf
      February 01, 2013 - Delay in Treatment: Failure to Contact Patient Leads to Significant Complications February 1, 2013 … Delay in Treatment: Failure to Contact Patient Leads to Significant Complications. … https://psnet.ahrq.gov/web-mm/delay-treatment-failure-contact-patient-leads-significant-complications … Case Objectives Know that failure to properly act on abnormal test results is a significant patient … Describe some steps that might reduce the harm from failure to act on abnormal test results.

1389. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49641/psn-pdf
      November 01, 2011 - Liver Failure After Chemotherapy: Did We Forget Something? November 1, 2011 Lubel J. … Liver Failure After Chemotherapy: Did We Forget Something? PSNet [internet]. 2011. … https://psnet.ahrq.gov/web-mm/liver-failure-after-chemotherapy-did-we-forget-something The Case A 51 … Luckily, she has made a complete recovery from her liver failure and is receiving chronic therapy for … Antiviral therapy may have prevented the patient's progression to acute liver failure.

1390. Double Dosing, by the Rules | PSNet
      psnet.ahrq.gov/web-mm/double-dosing-rules
      February 03, 2010 - The immediate success or failure of a strategic change can be easily identified once the change has been … However, the root cause of the error was actually a communication failure, because the physician failed … to communicate medications administered and patient outcomes during shift handoff; and (iii) failure … They should also consider conducting a failure mode and effect analysis to determine the potential … for failure and potential risk of harm.

1391. 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

1392. 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

1393. 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

1394. 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

1395. 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

1396. 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

1397. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42501/psn-pdf
      January 07, 2015 - epidemics—can be applied to monitor health information technologies for early signs of unreliability or failure

1398. 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

1399. 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

1400. 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