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Showing results for "failure".

141. Giving up learning from failures? An examination of learning from one's own failures in the context of heart surgeons. | PSNet
     psnet.ahrq.gov/issue/giving-learning-failures-examination-learning-ones-own-failures-context-heart-surgeons
     April 03, 2013 - Learning from failure is a key component of high reliability .

142. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50884/psn-pdf
     February 12, 2020 - Prescribing patterns of heart failure-exacerbating medications following a heart failure hospitalization … Prescribing patterns of heart failure-exacerbating medications following a heart failure hospitalization … - failure Various potentially inappropriately prescribed medications can exacerbate heart failure ( … https://psnet.ahrq.gov/issue/prescribing-patterns-heart-failure-exacerbating-medications-following-heart-failure … https://psnet.ahrq.gov/issue/prescribing-patterns-heart-failure-exacerbating-medications-following-heart-failure

143. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33596/psn-pdf
     June 01, 2025 - Failure to Rescue January 29, 2025 Tokareva I, Romano P. Failure to Rescue. … lead to FTR – failure to recognize complications, failure to relay information regarding complications … , and failure to react in a timely and appropriate manner. … Failure to rescue in surgical patients: a review for acute care surgeons. … Failure to rescue: a quality indicator for postoperative care.

144. Applying HFMEA to prevent chemotherapy errors. | PSNet
     psnet.ahrq.gov/issue/applying-hfmea-prevent-chemotherapy-errors
     September 27, 2017 - This study provides a practical example of using health care failure mode and effect analysis (FMEA … July 23, 2012 Healthcare failure mode and effect analysis (HFMEA) as an effective mechanism … May 9, 2012 View More Related Resources Using failure mode and … December 12, 2014 Failure mode and effects analysis: an empirical comparison of failure … December 15, 2010 Failure mode and effect analysis: a technique to prevent chemotherapy

145. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867633/psn-pdf
     February 26, 2025 - Failure to rescue female patients undergoing high-risk surgery. … Failure to rescue female patients undergoing high-risk surgery. … https://psnet.ahrq.gov/issue/failure-rescue-female-patients-undergoing-high-risk-surgery Failure-to-rescue … https://psnet.ahrq.gov/issue/failure-rescue-female-patients-undergoing-high-risk-surgery https://psnet.ahrq.gov … /primer/failure-rescue https://psnet.ahrq.gov/web-mm/failure-rescue-mother

146. Discharging Our Responsibility | PSNet
     psnet.ahrq.gov/web-mm/discharging-our-responsibility
     January 16, 2019 - Heart Failure Society of America. HFSA 2006 comprehensive heart failure practice guideline. … Clinical Performance Measures) endorsed by the Heart Failure Society of America. … Discharge education improves clinical outcomes in patients with chronic heart failure. … With The Guidelines (GWTG) heart failure program. … J Cardiac Failure 2006;12(suppl):S95.

147. Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator for Postoperative Respiratory Failure (PSI 11) does not identify accurately patients who received unsafe care. | PSNet
     psnet.ahrq.gov/issue/agency-healthcare-research-and-quality-ahrq-patient-safety-indicator-postoperative
     January 10, 2018 - Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator for Postoperative Respiratory Failure … Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator for Postoperative Respiratory Failure … used independent physician chart review to assess the reliability of PSI 11 (postoperative respiratory failure … Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator for Postoperative Respiratory Failure … March 2, 2011 Detection of postoperative respiratory failure: how predictive is the Agency

148. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60681/psn-pdf
     January 01, 2022 - Failure to rescue deteriorating patients: a systematic review of root causes and improvement strategies … Failure to rescue deteriorating patients: a systematic review of root causes and improvement strategies … https://psnet.ahrq.gov/issue/failure-rescue-deteriorating-patients-systematic-review-root-causes-and- … to rescue” among inpatients with serious complications – (1) failure to recognize the complications … ; (2) failure to relay information regarding the complications to the care team, and; (3) failure to

149. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74098/psn-pdf
     January 01, 2023 - Reducing failure to rescue rates in a paediatric in-patient setting: a 9-year quality improvement study … Reducing failure to rescue rates in a paediatric in?patient setting: a 9? … https://psnet.ahrq.gov/issue/reducing-failure-rescue-rates-paediatric-patient-setting-9-year-quality- … Over the nine-year period, failure to rescue events decreased from 23.6% to 2.5%. … https://psnet.ahrq.gov/primer/failure-rescue https://psnet.ahrq.gov/issue/failure-rescue-deteriorating-patients-systematic-review-root-causes-and-improvement

150. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74719/psn-pdf
     February 02, 2022 - Failure to rescue following emergency surgery: a FRAM analysis of the management of the deteriorating … Failure to rescue following emergency surgery: A FRAM analysis of the management of the deteriorating … Failure to rescue refers to delayed or missed recognition of a potentially fatal complication that … study sought to more effectively manage deteriorating patients after emergency surgery and reduce failure … https://psnet.ahrq.gov/primer/failure-rescue https://psnet.ahrq.gov/issue/interpersonal-and-organizational-dynamics-are-key-drivers-failure-rescue

151. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866343/psn-pdf
     December 31, 2024 - Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency December 31, 2024 Lee … Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency. … Role of high-dose intravenous nitrates in hypertensive acute heart failure. … in Congestive Heart Failure (MERIT-HF). … The role of the clinical examination in patients with heart failure.

152. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866195/psn-pdf
     June 26, 2024 - The exaggerated benefits of failure. … The exaggerated benefits of failure. … https://psnet.ahrq.gov/issue/exaggerated-benefits-failure Failure can be considered a learning opportunity … Respondents consistently overestimated the success rate following failure in each of the study scenarios … https://psnet.ahrq.gov/issue/exaggerated-benefits-failure https://psnet.ahrq.gov/issue/strategies-learning-failure

153. Post-discharge medication reviews for patients with heart failure: a pilot study. | PSNet
     psnet.ahrq.gov/issue/post-discharge-medication-reviews-patients-heart-failure-pilot-study
     May 21, 2009 - Study Post-discharge medication reviews for patients with heart failure: a pilot … Post-discharge medication reviews for patients with heart failure: a pilot study. … successfully implemented in order to improve postdischarge care for patients with congestive heart failure … Post-discharge medication reviews for patients with heart failure: a pilot study.

154. Management of anesthesia equipment failure: a simulation-based resident skill assessment. | PSNet
     psnet.ahrq.gov/issue/management-anesthesia-equipment-failure-simulation-based-resident-skill-assessment
     December 20, 2017 - Study Management of anesthesia equipment failure: a simulation-based resident skill … Management of Anesthesia Equipment Failure: A Simulation-Based Resident Skill Assessment. … Anesthesia residents' ability to handle intraoperative  equipment failure was evaluated using simulated … Management of Anesthesia Equipment Failure: A Simulation-Based Resident Skill Assessment.

155. Use of failure mode and effects analysis in improving the safety of i.v. drug administration. | PSNet
     psnet.ahrq.gov/issue/use-failure-mode-and-effects-analysis-improving-safety-iv-drug-administration
     March 23, 2012 - Study Use of failure mode and effects analysis in improving the safety of i.v. drug … Use of failure mode and effects analysis in improving the safety of i.v. drug administration. … The authors used failure mode and effects analysis (FMEA)  to identify dosing and administration errors … Use of failure mode and effects analysis in improving the safety of i.v. drug administration.

156. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73541/psn-pdf
     July 28, 2021 - Misdiagnosis of heart failure: a systematic review of the literature. … Misdiagnosis of heart failure: a systematic review of the literature. … J Cardiac Failure. 2021;27(9):925-933. doi:10.1016/j.cardfail.2021.05.014. … https://psnet.ahrq.gov/issue/misdiagnosis-heart-failure-systematic-review-literature Misdiagnosis of … This systematic review explored misdiagnosis of heart failure.

157. Patient Safety Essentials Toolkit. | PSNet
     psnet.ahrq.gov/issue/patient-safety-essentials-toolkit
     January 08, 2020 - Featured tools include the Situation-Background-Assessment-Recommendation approach, huddle agendas, and failure … December 21, 2014 Healthcare Failure Mode and Effect Analysis. … 17, 2012 Key performance outcomes of patient safety curricula: root cause analysis, failure … Topic Health Care Executives and Administrators Epidemiology of Errors and Adverse Events Failure

158. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74084/psn-pdf
     November 17, 2021 - Healthcare failure mode and effect analysis in the chemotherapy preparation process. … Healthcare failure mode and effect analysis in the chemotherapy preparation process. … Researchers in this study used healthcare failure mode and effect analysis (HFMEA) to identify and … Nine potential failure modes were identified – wrong label, drug, dose, solvent, or volume; non-sterile … Potential approaches to reduce these failure modes include updating the Standard Operating Procedures

159. A Missed Bowel Perforation - the Importance of Diagnostic Reasoning | PSNet
     psnet.ahrq.gov/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning
     January 29, 2021 - Sinigayan, MD, and Mithu Molla, MD, MBA This is an unfortunate case describing the failure to identify … RCA will guide this commentary with a focus on diagnostic failure, failure to identify and target early … volume overload, presumably heart failure, and this initial diagnosis likely had a powerful impact on … the failure to consider alternative diagnoses. … There was failure in the fourth step in the diagnostic process, verifying the diagnosis by ruling out

160. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73608/psn-pdf
     January 01, 2022 - Pharmacist-led intervention on the reduction of inappropriate medication use in patients with heart failure … Pharmacist-led intervention on the reduction of inappropriate medication use in patients with heart failure … involving pharmacists to reduce polypharmacy and inappropriate medications for patients with heart failure … successful when specific guidelines or recommendations to assess appropriate prescribing of heart failure … effect-pharmacist-counseling-intervention-health-care-utilization-following-hospital https://psnet.ahrq.gov/issue/prescribing-patterns-heart-failure-exacerbating-medications-following-heart-failure