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Showing results for "failure".

161. Making FMEA work for you. | PSNet
     psnet.ahrq.gov/issue/making-fmea-work-you
     July 01, 2019 - This commentary describes failure mode and effects analysis and discusses how it can improve patient … May 28, 2014 Failure mode and effects analysis: a useful tool for risk identification … October 3, 2011 Failure mode and effect analysis: a technique to prevent chemotherapy … About The Topic Nurses Nurse Managers Quality and Safety Professionals Nurse Care Failure

162. Spotlight
     psnet.ahrq.gov/sites/default/files/2024-07/spotlight_case_mismanagement_of_acute_decompensated_heart_failure_slides_final.pptx
     January 01, 2024 - Spotlight Spotlight Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency … Acute decompensated heart failure update. Curr Cardiol Rev. 2015;11(1):53-62. … Role of high-dose intravenous nitrates in hypertensive acute heart failure.  … Trial in Congestive Heart Failure (MERIT-HF). … The Role of the Clinical Examination in Patients With Heart Failure.

163. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/845637/psn-pdf
     March 08, 2023 - Using Failure Mode, Effect and Criticality Analysis to improve safety in the cancer treatment prescription … Using Failure Mode, Effect and Criticality Analysis to improve safety in the cancer treatment prescription … https://psnet.ahrq.gov/issue/using-failure-mode-effect-and-criticality-analysis-improve-safety-cancer … - treatment Failure Mode, Effect and Criticality Analysis (FMECA) is a prospective method for identifying … health medical residents calculated a Risk Priority Number (RPN), or criticality, for each possible failure

164. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74053/psn-pdf
     November 10, 2021 - Prevention of failure to rescue in obstetric patients: a realist review. … Prevention of failure to rescue in obstetric patients: a realist review. … https://psnet.ahrq.gov/issue/prevention-failure-rescue-obstetric-patients-realist-review Failure to … https://psnet.ahrq.gov/issue/prevention-failure-rescue-obstetric-patients-realist-review https://psnet.ahrq.gov … /primer/failure-rescue https://psnet.ahrq.gov/web-mm/failure-rescue-mother https://psnet.ahrq.gov/issue

165. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/72696/psn-pdf
     February 03, 2021 - Exploring the association between organizational safety climate, failure to rescue, and mortality in … Exploring the Association Between Organizational Safety Climate, Failure to Rescue, and Mortality in … https://psnet.ahrq.gov/issue/exploring-association-between-organizational-safety-climate-failure-rescue … - and-mortality Lack of communication and interpersonal dynamics can contribute to failure to rescue … safety climate, but the authors did not find an association between organizational safety culture and failure

166. Failure to follow-up test results for ambulatory patients: a systematic review. | PSNet
     psnet.ahrq.gov/issue/failure-follow-test-results-ambulatory-patients-systematic-review
     March 23, 2012 - Review Classic Failure to follow-up test results for ambulatory … Failure to Follow-Up Test Results for Ambulatory Patients: A Systematic Review. … This systematic review found evidence that failure to act on abnormal radiology or laboratory results … Failure to Follow-Up Test Results for Ambulatory Patients: A Systematic Review. … March 23, 2011 Frequency of failure to inform patients of clinically significant outpatient

167. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/845277/psn-pdf
     March 01, 2023 - Risk assessment of the acute stroke diagnostic process using failure modes, effects, and criticality … Risk assessment of the acute stroke diagnostic process using failure modes, effects, and criticality … https://psnet.ahrq.gov/issue/risk-assessment-acute-stroke-diagnostic-process-using-failure-modes-effects … to screen patients for stroke soon after presentation to the Emergency Department (ED), failure to … obtain an accurate history, and failure to consider a stroke diagnosis during triage.

168. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73371/psn-pdf
     June 09, 2021 - Reducing failures in daily medical practice: healthcare failure mode and effect analysis combined with … Reducing failures in daily medical practice: healthcare failure mode and effect analysis combined with … https://psnet.ahrq.gov/issue/reducing-failures-daily-medical-practice-healthcare-failure-mode-and-effect … - analysis-combined Failure mode and effect analysis (FMEA) is widely used to identify latent safety … The authors of this study proposed combining healthcare failure mode and effect analysis (HFMEA) with

169. The AMÉLIE project: failure mode, effects and criticality analysis: a model to evaluate the nurse medication administration process on the floor. | PSNet
     psnet.ahrq.gov/issue/amelie-project-failure-mode-effects-and-criticality-analysis-model-evaluate-nurse-medication
     September 24, 2016 - Study The AMÉLIE project: failure mode, effects and criticality analysis: a model … The AMÉLIE project: failure mode, effects and criticality analysis: a model to evaluate the nurse medication … This study reports on a multidisciplinary failure mode and effect analysis of nursing medication administration … The AMÉLIE project: failure mode, effects and criticality analysis: a model to evaluate the nurse medication

170. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/865817/psn-pdf
     May 08, 2024 - Using Healthcare Failure Mode and Effect Analysis in prospective medication safety risk management in … Using Healthcare Failure Mode and Effect Analysis in prospective medication safety risk management in … https://psnet.ahrq.gov/issue/using-healthcare-failure-mode-and-effect-analysis-prospective-medication … In this study, a hospital used Healthcare Failure Mode and Effect Analysis (HFMEA) to prospectively … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-reduce-risk-heparin-use https://psnet.ahrq.gov

171. Care Deficiencies and Leaders' Inadequate Reviews of a Patient Who Died at the Lt. Col. Luke Weathers, Jr. VA Medical Center in Memphis, Tennessee. | PSNet
     psnet.ahrq.gov/issue/care-deficiencies-and-leaders-inadequate-reviews-patient-who-died-lt-col-luke-weathers-jr-va
     April 10, 2024 - This analysis examines a case of communication failure during cardiac telemetry processes that resulted … March 5, 2025 Failure to rescue female patients undergoing high-risk surgery. … September 13, 2023 Reducing failure to rescue rates in a paediatric in-patient setting … About The Topic Hospitals Critical Care Hospital Medicine Critical Care Nursing Failure

172. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/854992/psn-pdf
     November 01, 2023 - Failure to rescue as a patient safety indicator for neurosurgical patients: are we there yet? … Failure to rescue as a patient safety indicator for neurosurgical patients: are we there yet? … https://psnet.ahrq.gov/issue/failure-rescue-patient-safety-indicator-neurosurgical-patients-are-we-there-yet … Failure to rescue (FTR) quality metrics measure the ability of healthcare teams and hospitals to prevent … https://psnet.ahrq.gov/primer/failure-rescue https://psnet.ahrq.gov/issue/failure-rescue-deteriorating-patients-systematic-review-root-causes-and-improvement

173. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/72632/psn-pdf
     January 13, 2021 - Algorithmic prediction of failure modes in healthcare. … Algorithmic prediction of failure modes in healthcare. … https://psnet.ahrq.gov/issue/algorithmic-prediction-failure-modes-healthcare Failure mode and effect … This study found that an algorithmic prediction of failure modes in healthcare (APFMH) is more effective … https://psnet.ahrq.gov/issue/algorithmic-prediction-failure-modes-healthcare https://psnet.ahrq.gov/issue

174. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/48162/psn-pdf
     July 24, 2019 - Allowing failure for educational purposes in postgraduate clinical training: a narrative review. … Allowing failure for educational purposes in postgraduate clinical training: A narrative review. … https://psnet.ahrq.gov/issue/allowing-failure-educational-purposes-postgraduate-clinical-training-narrative … - review Learning from failure is more appropriate in some contexts than others. … https://psnet.ahrq.gov/issue/allowing-failure-educational-purposes-postgraduate-clinical-training-narrative-review

175. 20 years later: to err is a leadership failure. | PSNet
     psnet.ahrq.gov/issue/20-years-later-err-leadership-failure
     November 30, 2016 - Special or Theme Issue 20 years later: to err is a leadership failure. … Citation Text: 20 years later: to err is a leadership failure. Castellucci M, Meyer H. … Cite Citation Citation Text: 20 years later: to err is a leadership failure … March 8, 2019 Heart Failure: The Decline of a Historic Transplant Program.

176. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47820/psn-pdf
     May 11, 2019 - Missed diagnosis of new-onset systolic heart failure at first presentation in children with no known … Missed diagnosis of new-onset systolic heart failure at first presentation in children with no known … https://psnet.ahrq.gov/issue/missed-diagnosis-new-onset-systolic-heart-failure-first-presentation-children … no-known-heart In this retrospective study, researchers found that the diagnosis of systolic heart failure … missed on first presentation for almost 50% of pediatric patients hospitalized with new-onset heart failure

177. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866395/psn-pdf
     July 23, 2024 - Failure to rescue can lead to a significant adverse event, such as death or disability.2 The RIC is … .6 Work to improve failure to rescue has since been ongoing. … Rescue improvement conference: a novel tool for addressing failure to rescue. … Failure to rescue. PSNet. Agency for Healthcare Research and Quality. September 7, 2019. … https://psnet.ahrq.gov/primer/failure-rescue

178. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73471/psn-pdf
     July 07, 2021 - Rapid response teams as a patient safety practice for failure to rescue. … Rapid Response Teams as a Patient Safety Practice for Failure to Rescue. … https://psnet.ahrq.gov/issue/rapid-response-teams-patient-safety-practice-failure-rescue Rapid response … evidence included in the AHRQ Making Healthcare Safer III report about the use of RRTs to decrease failure … https://psnet.ahrq.gov/issue/rapid-response-teams-patient-safety-practice-failure-rescue https://psnet.ahrq.gov

179. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/851651/psn-pdf
     July 26, 2023 - Using failure mode and effect analysis to identify potential failures in a psychiatric hospital emergency … Using failure mode and effect analysis to identify potential failures in a psychiatric hospital emergency … https://psnet.ahrq.gov/issue/using-failure-mode-and-effect-analysis-identify-potential-failures-psychiatric … - hospital Failure mode and effect analysis (FMEA) is a common way to identify error risk. … https://psnet.ahrq.gov/issue/using-failure-mode-and-effect-analysis-identify-potential-failures-psychiatric-hospital

180. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50852/psn-pdf
     January 29, 2020 - Failure mode and effects analysis to reduce risk of heparin use. … Failure mode and effects analysis to reduce risk of heparin use. … This study used a failure mode and effects analysis (FMEA) to prospectively analyze various steps in … The FMEA identified 233 potential failures and 737 potential causes of failure. … Underlying causes of failure included mathematical errors, EHR challenges, and varying practice and