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psnet.ahrq.gov/print/pdf/node/865308
January 01, 2024 - impact of
failure on organisational learning. … foundational-science-learning-health-systems
https://psnet.ahrq.gov/issue/interactions-between-context-health-care-organisation-and-failure-situational-impact-failure … https://psnet.ahrq.gov/issue/interactions-between-context-health-care-organisation-and-failure-situational-impact-failure … situational impact of
failure on organisational learning. … https://psnet.ahrq.gov/issue/interactions-between-context-health-care-organisation-and-failure-situational-impact-failure
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psnet.ahrq.gov/issue/basics-fmea-2nd-edition
October 23, 2013 - The authors provide a handbook that serves as the core tool for understanding and implementing the failure … to be used by technical and administrative employees at all levels to learn about opportunities for failure … November 21, 2016
Failure mode and effects analysis: a comparison of two common risk … May 4, 2016
Strategies and tips for maximizing failure mode and effect analysis in your … See More About The Topic
Health Care Providers
Non-Health Care Professionals
Failure
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psnet.ahrq.gov/issue/improving-accuracy-patient-identification-medication-use-process
May 09, 2014 - Investigators from a tertiary care academic medical center describe a failure mode and effects analysis … August 31, 2022
Algorithmic prediction of failure modes in healthcare. … January 22, 2017
A proactive risk avoidance system using failure mode and effects analysis … November 1, 2010
Is failure mode and effect analysis reliable? … The Topic
General Hospitals
Quality and Safety Professionals
Identification Errors
Failure
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psnet.ahrq.gov/issue/safety-critical-care-medicine
July 14, 2021 - Topics covered include the use of failure mode and effects analysis , organizational and cultural strategies … July 16, 2009
Failure mode and effects analysis application to critical care medicine … The Topic
Physicians
Critical Care
Medication Errors/Preventable Adverse Drug Events
Failure
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psnet.ahrq.gov/node/50574/psn-pdf
October 23, 2019 - Occupational stress and cognitive failure of nurses and
associations with on self-reported adverse events … Occupational stress and cognitive failure of nurses and
associations with self-reported adverse events … https://psnet.ahrq.gov/issue/occupational-stress-and-cognitive-failure-nurses-and-associations-self- … https://psnet.ahrq.gov/issue/occupational-stress-and-cognitive-failure-nurses-and-associations-self-reported-adverse … https://psnet.ahrq.gov/issue/occupational-stress-and-cognitive-failure-nurses-and-associations-self-reported-adverse
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psnet.ahrq.gov/node/853244/psn-pdf
September 06, 2023 - This article highlights five patient safety risks
during pediatric perioperative blood management (failure … to recognize and treat preoperative anemia,
failure to obtain informed consent regarding perioperative … blood management, failure to consider specific
intraoperative blood conservation techniques in children … , failure to recognize massive hemorrhage, failure
to prevent unnecessary transfusion).
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psnet.ahrq.gov/node/60648/psn-pdf
July 01, 2020 - Chronicle of a pandemic foretold: learning from the
COVID-19 failure—before the next outbreak arrives … Chronicle of a pandemic foretold: learning from the COVID-19 failure—before
the next outbreak arrives … https://psnet.ahrq.gov/issue/chronicle-pandemic-foretold-learning-covid-19-failure-next-outbreak-arrives … This article examines the COVID-19
pandemic through a system failure lens. … https://psnet.ahrq.gov/issue/chronicle-pandemic-foretold-learning-covid-19-failure-next-outbreak-arrives
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psnet.ahrq.gov/node/40060/psn-pdf
December 15, 2010 - Failure mode and effects analysis: an empirical
comparison of failure mode scoring procedures. … Failure Mode and Effects Analysis. J Patient Saf. 2010;6(4):210-215. … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-empirical-comparison-failure-mode-scoring … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-empirical-comparison-failure-mode-scoring-procedures … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-empirical-comparison-failure-mode-scoring-procedures
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psnet.ahrq.gov/node/60525/psn-pdf
May 27, 2020 - Public sector organizational failure: a study of collective
denial in the UK national health service … Public sector organizational failure: a study of collective denial in the UK national
health service … https://psnet.ahrq.gov/issue/public-sector-organizational-failure-study-collective-denial-uk-national-health … https://psnet.ahrq.gov/issue/public-sector-organizational-failure-study-collective-denial-uk-national-health-service … https://psnet.ahrq.gov/issue/public-sector-organizational-failure-study-collective-denial-uk-national-health-service
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psnet.ahrq.gov/node/838012/psn-pdf
September 07, 2022 - The physiology of failure: identifying risk factors for
mortality in emergency general surgery patients … The physiology of failure: identifying risk factors for
mortality in emergency general surgery patients … https://psnet.ahrq.gov/issue/physiology-failure-identifying-risk-factors-mortality-emergency-general-surgery … https://psnet.ahrq.gov/issue/physiology-failure-identifying-risk-factors-mortality-emergency-general-surgery-patients … https://psnet.ahrq.gov/issue/physiology-failure-identifying-risk-factors-mortality-emergency-general-surgery-patients
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psnet.ahrq.gov/node/50686/psn-pdf
January 01, 2020 - 'Whatever you cut, I can fix it': clinical supervisors'
interview accounts of allowing trainee failure … ‘Whatever you cut, I can fix it’: clinical supervisors’ interview
accounts of allowing trainee failure … whatever-you-cut-i-can-fix-it-clinical-supervisors-interview-accounts-allowing-
trainee
This qualitative study explored physicians experience allowing for failure … Allowing supervised failure was perceived to be an important element of trainee
development and was … whatever-you-cut-i-can-fix-it-clinical-supervisors-interview-accounts-allowing-trainee
https://psnet.ahrq.gov/issue/strategies-learning-failure
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psnet.ahrq.gov/node/73630/psn-pdf
August 25, 2021 - Towards safer healthcare: qualitative insights from a
process view of organisational learning from failure … Towards safer healthcare: qualitative insights from a process view of
organisational learning from failure … psnet.ahrq.gov/issue/towards-safer-healthcare-qualitative-insights-process-view-organisational-
learning-failure … psnet.ahrq.gov/issue/towards-safer-healthcare-qualitative-insights-process-view-organisational-learning-failure … psnet.ahrq.gov/issue/towards-safer-healthcare-qualitative-insights-process-view-organisational-learning-failure
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psnet.ahrq.gov/node/844047/psn-pdf
February 08, 2023 - Using trainee failures to enhance learning: a qualitative
study of pediatric hospitalists on allowing failure … Using trainee failures to enhance learning: a qualitative study of
pediatric hospitalists on allowing failure … In this study, pediatric hospitalists describe potential benefits and risks of
allowing failure, the … process of allowing or interrupting failure, and how they decide to allow failure to
happen.
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psnet.ahrq.gov/node/73976/psn-pdf
October 20, 2021 - A retrospective analysis demonstrates that a failure to
document key comorbid diseases in the anesthesia … A retrospective analysis demonstrates that a failure to document key
comorbid diseases in the anesthesia … https://psnet.ahrq.gov/issue/retrospective-analysis-demonstrates-failure-document-key-comorbid-diseases … https://psnet.ahrq.gov/issue/retrospective-analysis-demonstrates-failure-document-key-comorbid-diseases-anesthesia … https://psnet.ahrq.gov/issue/retrospective-analysis-demonstrates-failure-document-key-comorbid-diseases-anesthesia
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psnet.ahrq.gov/node/61119/psn-pdf
November 11, 2020 - Misdiagnosis and failure to diagnose in emergency care:
causes and empathy as a solution. … Misdiagnosis and failure to diagnose in emergency care: causes and
empathy as a solution. … https://psnet.ahrq.gov/issue/misdiagnosis-and-failure-diagnose-emergency-care-causes-and-empathy-
solution … https://psnet.ahrq.gov/issue/misdiagnosis-and-failure-diagnose-emergency-care-causes-and-empathy-solution … https://psnet.ahrq.gov/issue/misdiagnosis-and-failure-diagnose-emergency-care-causes-and-empathy-solution
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psnet.ahrq.gov/node/867845/psn-pdf
February 26, 2025 - technique to analyze numerous patient safety reports, aggregate proactive risk
assessments (e.g., Failure … Bender and Steve Kulju, two members of the NCPS team, report that NCPS piloted CPRA in
2020 using Failure … The flow diagram summarizes the process and
reveals a list of all failure modes. … Approximately one-
third of failure modes (n=14) were identified by at least one facility, and about … three-quarters of failure
modes (n=32) were not analyzed by any of the 3 facilities in the proactive
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psnet.ahrq.gov/node/60593/psn-pdf
June 17, 2020 - Failure to follow medication changes made at hospital
discharge is associated with adverse events in … Failure to follow medication changes made at hospital
discharge is associated with adverse events in … https://psnet.ahrq.gov/issue/failure-follow-medication-changes-made-hospital-discharge-associated-
adverse-events … https://psnet.ahrq.gov/issue/failure-follow-medication-changes-made-hospital-discharge-associated-adverse-events … -30-days
https://psnet.ahrq.gov/issue/failure-follow-medication-changes-made-hospital-discharge-associated-adverse-events
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psnet.ahrq.gov/node/50832/psn-pdf
January 01, 2021 - Preventing critical failure. … Preventing critical failure. … https://psnet.ahrq.gov/issue/preventing-critical-failure-can-routinely-collected-data-be-repurposed-predict … https://psnet.ahrq.gov/issue/preventing-critical-failure-can-routinely-collected-data-be-repurposed-predict-avoidable … https://psnet.ahrq.gov/issue/preventing-critical-failure-can-routinely-collected-data-be-repurposed-predict-avoidable
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psnet.ahrq.gov/node/842416/psn-pdf
January 11, 2023 - A failure in the medication delivery system-how
disclosure and systems investigation improve patient … A failure in the medication delivery system—how disclosure and systems
investigation improve patient … https://psnet.ahrq.gov/issue/failure-medication-delivery-system-how-disclosure-and-systems-investigation … https://psnet.ahrq.gov/issue/failure-medication-delivery-system-how-disclosure-and-systems-investigation-improve-patient … https://psnet.ahrq.gov/issue/failure-medication-delivery-system-how-disclosure-and-systems-investigation-improve-patient
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psnet.ahrq.gov/issue/using-proactive-risk-assessment-hfmea-improve-patient-safety-and-quality-associated
September 19, 2016 - Researchers used failure mode and effects analysis to examine intraocular lens implantation. … They report uncovering many potential failure modes or safety vulnerabilities and extensive variation … October 18, 2023
Using Health Care Failure Mode and Effect Analysis: the VA National … September 13, 2023
Reducing failures in daily medical practice: healthcare failure mode … October 24, 2018
Applicability of Healthcare Failure Mode and Effects Analysis to healthcare