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Showing results for "failure".

181. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/72468/psn-pdf
     November 18, 2020 - Development of rapid response capabilities in a large COVID-19 alternate care site using Failure Modes … Development of rapid response capabilities in a large COVID-19 alternate care site using Failure Modes … psnet.ahrq.gov/issue/development-rapid-response-capabilities-large-covid-19-alternate-care-site- using-failure … Health system leadership used failure modes and effect analysis, process mapping, and on-site walkthroughs … psnet.ahrq.gov/issue/development-rapid-response-capabilities-large-covid-19-alternate-care-site-using-failure

182. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50824/psn-pdf
     January 22, 2020 - Failure to rescue and 30-day in-hospital mortality in hospitals with and without crew-resource-management … Failure to rescue and 30?day in?hospital mortality in hospitals with and without crew?resource? … https://psnet.ahrq.gov/issue/failure-rescue-and-30-day-hospital-mortality-hospitals-and-without-crew- … impact of crew resource management (CRM) training for surgical staff and organizational leadership on failure … https://psnet.ahrq.gov/issue/failure-rescue-and-30-day-hospital-mortality-hospitals-and-without-crew-resource-management

183. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/852278/psn-pdf
     August 09, 2023 - Identifying failure modes in telemedicine: an instructional needs assessment. … Identifying failure modes in telemedicine: an instructional needs assessment. … https://psnet.ahrq.gov/issue/identifying-failure-modes-telemedicine-instructional-needs-assessment Implementation … In this study, medical students used Healthcare Failure Modes and Effect Analysis to identify the causes … https://psnet.ahrq.gov/issue/identifying-failure-modes-telemedicine-instructional-needs-assessment https

184. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74212/psn-pdf
     January 01, 2022 - Using failure mode and effects analysis to increase patient safety in cancer chemotherapy. … Using Failure Mode and Effects Analysis to increase patient safety in cancer chemotherapy. … https://psnet.ahrq.gov/issue/using-failure-mode-and-effects-analysis-increase-patient-safety-cancer- … Using failure mode and effects analysis (FMEA), researchers identified potential failures related to … https://psnet.ahrq.gov/issue/using-failure-mode-and-effects-analysis-increase-patient-safety-cancer-chemotherapy

185. Microsoft PowerPoint - Spotlight Case_A Missed Bowel Perforation - SLIDES_FINAL.pptx (pdf file)
     psnet.ahrq.gov/sites/default/files/2023-09/a_missed_bowel_perforation_-_the_importance_of_diagnostic_reasoning.pdf
     January 01, 2023 - BOWEL PERFORATION – THE IMPORTANCE OF DIAGNOSTIC REASONING A case highlighting describing how the failure … RCA will guide this commentary with a focus on diagnostic failure, failure to identify and target early … was identified. 11 DIAGNOSTIC FAILURE 12 Diagnostic Failure (1) This patient was initially … admitted to the cardiac care unit with symptoms suggesting volume overload, presumably heart failure … Atrial fibrillation (not described here) and heart failure would put her at risk for an embolus to

186. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47584/psn-pdf
     February 20, 2019 - Patient involvement in evaluation of safety in oral antineoplastic treatment: a failure mode and effects … Patient Involvement in Evaluation of Safety in Oral Antineoplastic Treatment: A Failure Mode and Effects … https://psnet.ahrq.gov/issue/patient-involvement-evaluation-safety-oral-antineoplastic-treatment-failure … - mode-and-effects This study employed failure mode and effect analysis to detect risks in oral chemotherapy … https://psnet.ahrq.gov/issue/patient-involvement-evaluation-safety-oral-antineoplastic-treatment-failure-mode-and-effects

187. Risk and pharmacoeconomic analyses of the injectable medication process in the paediatric and neonatal intensive care units. | PSNet
     psnet.ahrq.gov/issue/risk-and-pharmacoeconomic-analyses-injectable-medication-process-paediatric-and-neonatal
     December 17, 2014 - This study used failure modes and effects analysis to identify the major hazards associated with intravenous … November 29, 2023 Using Failure Mode, Effect and Criticality Analysis to improve safety … December 19, 2018 View More Related Resources Using failure mode … in the implementation and use of smart pumps in a pediatric intensive care unit: application of the failure … June 16, 2010 Random safety auditing, root cause analysis, failure mode and effects analysis

188. Premature Extubation | PSNet
     psnet.ahrq.gov/web-mm/premature-extubation
     May 25, 2011 - Only one-third of patients who required intubation were considered high risk for extubation failure by … , heart failure, or encephalopathy instead of stridor). … There is currently no consensus on optimal therapies to prevent extubation failure. … Risk factors for extubation failure in patients following a successful spontaneous breathing trial. … The Spanish Lung Failure Collaborative Group. Am J Respir Crit Care Med. 1997;156(2 pt 1):459-465.

189. Contributing factors for pediatric ambulatory diagnostic process errors: Project RedDE. | PSNet
     psnet.ahrq.gov/issue/contributing-factors-pediatric-ambulatory-diagnostic-process-errors-project-redde
     November 30, 2022 - Building upon previous work , this study used root cause analyses to identify the failure points and … Omitted process steps included failure to screen for adolescent depression, failure to recognize and … act on abnormal blood pressure values, and failure to notify families of abnormal lab results.

190. A risk analysis method to evaluate the impact of a Computerized Provider Order Entry system on patient safety. | PSNet
     psnet.ahrq.gov/issue/risk-analysis-method-evaluate-impact-computerized-provider-order-entry-system-patient-safety
     September 15, 2021 - This study conducted a detailed quantitative analysis, following a failure mode and effect analysis ( … June 29, 2022 Healthcare failure mode and effect analysis in the chemotherapy preparation … May 27, 2011 Error reduction in pediatric chemotherapy: computerized order entry and failure … Professionals Information Professionals Medication Safety Continuous Quality Improvement Failure

191. Trainees' perceptions of being allowed to fail in clinical training: a sense-making model. | PSNet
     psnet.ahrq.gov/issue/trainees-perceptions-being-allowed-fail-clinical-training-sense-making-model
     November 24, 2021 - This qualitative study, which included postgraduate trainees from Europe and Canada, concluded that failure … 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 … April 14, 2021 Allowing failure for educational purposes in postgraduate clinical training

192. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867340/psn-pdf
     December 11, 2024 - Multiple points of system failure underpin continuous subcutaneous infusion safety incidents in palliative … Multiple points of system failure underpin continuous subcutaneous infusion safety incidents in palliative … https://psnet.ahrq.gov/issue/multiple-points-system-failure-underpin-continuous-subcutaneous-infusion … https://psnet.ahrq.gov/issue/multiple-points-system-failure-underpin-continuous-subcutaneous-infusion-safety-incidents … https://psnet.ahrq.gov/issue/multiple-points-system-failure-underpin-continuous-subcutaneous-infusion-safety-incidents

193. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/72856/psn-pdf
     March 17, 2021 - The fusion of incident learning and failure mode and effects analysis for data-driven patient safety … The fusion of incident learning and failure mode and effects analysis for data-driven patient safety … https://psnet.ahrq.gov/issue/fusion-incident-learning-and-failure-mode-and-effects-analysis-data-driven … authors propose a method which leverages a radiation oncology incident learning system with a simplified failure … https://psnet.ahrq.gov/issue/fusion-incident-learning-and-failure-mode-and-effects-analysis-data-driven-patient-safety

194. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/72682/psn-pdf
     January 27, 2021 - Healthcare failure mode and effect analysis (HFMEA) as an effective mechanism in preventing infection … Healthcare Failure Mode and Effect Analysis (HFMEA) as an Effective Mechanism in Preventing Infection … https://psnet.ahrq.gov/issue/healthcare-failure-mode-and-effect-analysis-hfmea-effective-mechanism- … This article describes the use of healthcare failure mode and effects analysis (HFMEA) 4- step model … https://psnet.ahrq.gov/issue/healthcare-failure-mode-and-effect-analysis-hfmea-effective-mechanism-preventing-infection

195. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/844769/psn-pdf
     January 01, 2020 - Failure to administer recommended chemotherapy: acceptable variation or cancer care quality blind spot … Failure to administer recommended chemotherapy: acceptable variation or cancer care quality blind spot … https://psnet.ahrq.gov/issue/failure-administer-recommended-chemotherapy-acceptable-variation-or- cancer-care-quality-blind … The authors conclude that failure to administer chemotherapy is a significant safety gap that should … https://psnet.ahrq.gov/issue/failure-administer-recommended-chemotherapy-acceptable-variation-or-cancer-care-quality-blind

196. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866517/psn-pdf
     August 14, 2024 - Feedback loop failure modes in medical diagnosis: how biases can emerge and be reinforced. … Feedback loop failure modes in medical diagnosis: how biases can emerge and be reinforced. … https://psnet.ahrq.gov/issue/feedback-loop-failure-modes-medical-diagnosis-how-biases-can-emerge-and- … https://psnet.ahrq.gov/issue/feedback-loop-failure-modes-medical-diagnosis-how-biases-can-emerge-and-be-reinforced … https://psnet.ahrq.gov/issue/feedback-loop-failure-modes-medical-diagnosis-how-biases-can-emerge-and-be-reinforced

197. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46807/psn-pdf
     July 02, 2019 - Communication failure: analysis of prescribers' use of an internal free-text field on electronic prescriptions … Communication failure: analysis of prescribers’ use of an internal free-text field on electronic prescriptions … https://psnet.ahrq.gov/issue/communication-failure-analysis-prescribers-use-internal-free-text-field- … More than 10% of medication orders exhibited a communication failure between prescriber and pharmacist … https://psnet.ahrq.gov/issue/communication-failure-analysis-prescribers-use-internal-free-text-field-electronic

198. Operating room to intensive care unit handoffs and the risks of patient harm. | PSNet
     psnet.ahrq.gov/issue/operating-room-intensive-care-unit-handoffs-and-risks-patient-harm
     October 05, 2022 - This research group performed a failure mode and effect analysis to study handoffs between the operating … November 20, 2015 Applicability of Healthcare Failure Mode and Effects Analysis to healthcare … May 19, 2015 Health care failure mode and effect analysis to reduce NICU line–associated … March 28, 2011 Use of failure mode and effects analysis for proactive identification

199. Use of FMEA analysis to reduce risk of errors in prescribing and administering drugs in paediatric wards: a quality improvement report. | PSNet
     psnet.ahrq.gov/issue/use-fmea-analysis-reduce-risk-errors-prescribing-and-administering-drugs-paediatric-wards
     March 08, 2023 - Failure mode and effect analysis identified calculation errors as a major source of medication errors … Download Citation Related Resources From the Same Author(s) Using Failure … Improving Diagnostic Safety and Quality April 26, 2023 Using failure … December 9, 2020 The AMÉLIE project: failure mode, effects and criticality analysis:

200. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73241/psn-pdf
     May 12, 2021 - Delayed or failure to follow-up abnormal breast cancer screening mammograms in primary care: a systematic … Delayed or failure to follow-up abnormal breast cancer screening mammograms in primary care: a systematic … https://psnet.ahrq.gov/issue/delayed-or-failure-follow-abnormal-breast-cancer-screening-mammograms- … https://psnet.ahrq.gov/issue/delayed-or-failure-follow-abnormal-breast-cancer-screening-mammograms-primary-care-systematic … https://psnet.ahrq.gov/issue/delayed-or-failure-follow-abnormal-breast-cancer-screening-mammograms-primary-care-systematic