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Showing results for "failure".

221. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49856/psn-pdf
     March 01, 2019 - Only one-third of patients who required intubation were considered high risk for extubation failure … , 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.

222. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47502/psn-pdf
     June 02, 2019 - Failure to debrief after critical events in anesthesia is associated with failures in communication … Failure to Debrief after Critical Events in Anesthesia Is Associated with Failures in Communication … https://psnet.ahrq.gov/issue/failure-debrief-after-critical-events-anesthesia-associated-failures- communication-during … https://psnet.ahrq.gov/issue/failure-debrief-after-critical-events-anesthesia-associated-failures-communication-during … https://psnet.ahrq.gov/issue/failure-debrief-after-critical-events-anesthesia-associated-failures-communication-during

223. Combined Proactive Risk Assessment (CPRA) – 4-Step Technique Innovation Summary | PSNet
     psnet.ahrq.gov/innovation/combined-proactive-risk-assessment-cpra-4-step-technique-innovation-summary
     February 26, 2025 - ) technique to analyze numerous patient safety reports, aggregate proactive risk assessments (e.g., Failure … with main process steps and sub-steps depicting how the flow of outpatient blood draws and revealing 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

224. PSNet Curated Library (pdf file)
     psnet.ahrq.gov/print/pdf/node/867659
     July 10, 2024 - piece discusses surveillance monitoring of patients in low-acuity units of the hospital to prevent failure … Web M&Ms Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to … https://psnet.ahrq.gov/web-mm/hemorrhagic-shock-after-elective-spine-surgery-failure-rescue-after-limited-response-nursing … All Library Content Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited … piece discusses surveillance monitoring of patients in low-acuity units of the hospital to prevent failure

225. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47583/psn-pdf
     December 05, 2018 - Interpersonal and organizational dynamics are key drivers of failure to rescue. … Interpersonal And Organizational Dynamics Are Key Drivers Of Failure To Rescue. … https://psnet.ahrq.gov/issue/interpersonal-and-organizational-dynamics-are-key-drivers-failure-rescue … Stakeholders at five Michigan hospitals identified two changeable causes of failure to rescue: delayed … https://psnet.ahrq.gov/issue/interpersonal-and-organizational-dynamics-are-key-drivers-failure-rescue

226. A retrospective analysis demonstrates that a failure to document key comorbid diseases in the anesthesia preoperative evaluation associates with increased length of stay and mortality. | PSNet
     psnet.ahrq.gov/issue/retrospective-analysis-demonstrates-failure-document-key-comorbid-diseases-anesthesia
     May 26, 2021 - Study A retrospective analysis demonstrates that a failure to document key comorbid … 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 … The quality of hospital work environments and missed nursing care is linked to heart failure

227. Medicines management support to older people: understanding the context of systems failure. | PSNet
     psnet.ahrq.gov/issue/medicines-management-support-older-people-understanding-context-systems-failure
     October 04, 2023 - Medicines management support to older people: understanding the context of systems failure … Medicines management support to older people: understanding the context of systems failure. … Medicines management support to older people: understanding the context of systems failure. … October 4, 2023 Surgical case listing accuracy: failure analysis at a high-volume academic

228. Implications of the failure to identify high-risk electrocardiogram findings for the quality of care of patients with acute myocardial infarction: results of the Emergency Department Quality in Myocardial Infarction (EDQMI) study. | PSNet
     psnet.ahrq.gov/issue/implications-failure-identify-high-risk-electrocardiogram-findings-quality-care-patients
     July 07, 2021 - Study Implications of the failure to identify high-risk electrocardiogram findings … Implications of the failure to identify high-risk electrocardiogram findings for the quality of care … Implications of the failure to identify high-risk electrocardiogram findings for the quality of care … January 13, 2010 A failure in the medication delivery system-how disclosure and systems

229. Escalation of care in surgery: a systematic risk assessment to prevent avoidable harm in hospitalized patients. | PSNet
     psnet.ahrq.gov/issue/escalation-care-surgery-systematic-risk-assessment-prevent-avoidable-harm-hospitalized
     December 17, 2014 - Delays in this process can lead to critical failure-to-rescue events, which may result in preventable … This study used ethnographic observations, a risk assessment survey, and a formal health care failure … September 9, 2015 A systematic review to identify the factors that affect failure to … September 12, 2016 Escalation of care and failure to rescue: a multicenter, multiprofessional … September 10, 2014 Augmenting health care failure modes and effects analysis with simulation

230. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44756/psn-pdf
     September 12, 2016 - Importance of teamwork, communication and culture on failure-to-rescue in the elderly. … Importance of teamwork, communication and culture on failure-to-rescue in the elderly. … https://psnet.ahrq.gov/issue/importance-teamwork-communication-and-culture-failure-rescue-elderly Failure-to-rescue … The authors suggest that teamwork and communication improvement can help reduce failure-to-rescue in … https://psnet.ahrq.gov/issue/importance-teamwork-communication-and-culture-failure-rescue-elderly https

231. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/838022/psn-pdf
     September 07, 2022 - Organisational failure: rethinking whistleblowing for tomorrow's doctors. … Organisational failure: rethinking whistleblowing for tomorrow’s doctors. … https://psnet.ahrq.gov/issue/organisational-failure-rethinking-whistleblowing-tomorrows-doctors Normalization … https://psnet.ahrq.gov/issue/organisational-failure-rethinking-whistleblowing-tomorrows-doctors https

232. Variation in hospital mortality associated with inpatient surgery. | PSNet
     psnet.ahrq.gov/issue/variation-hospital-mortality-associated-inpatient-surgery
     August 02, 2015 - Surgical Quality Improvement Program to examine whether mortality after surgery was also influenced by " failure … to rescue "—failure to recognize and treat complications.  … August 20, 2018 Importance of teamwork, communication and culture on failure-to-rescue … September 24, 2017 Interpersonal and organizational dynamics are key drivers of failure … October 14, 2020 Failure events in transition of care for surgical patients.

233. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/838175/psn-pdf
     September 28, 2022 - Modes of failure in venous thromboembolism prophylaxis. … Modes of failure in venous thromboembolism prophylaxis. … https://psnet.ahrq.gov/issue/modes-failure-venous-thromboembolism-prophylaxis Hospital-acquired venous … https://psnet.ahrq.gov/issue/modes-failure-venous-thromboembolism-prophylaxis https://psnet.ahrq.gov/

234. The competent surgeon: individual accountability in the era of "systems" failure. | PSNet
     psnet.ahrq.gov/issue/competent-surgeon-individual-accountability-era-systems-failure
     May 30, 2014 - Commentary The competent surgeon: individual accountability in the era of "systems" failure … The competent surgeon: individual accountability in the era of "systems" failure. … The competent surgeon: individual accountability in the era of "systems" failure.

235. Learning from failure: the need for independent safety investigation in healthcare. | PSNet
     psnet.ahrq.gov/issue/learning-failure-need-independent-safety-investigation-healthcare
     September 24, 2018 - Commentary Learning from failure: the need for independent safety investigation in … Learning from failure: the need for independent safety investigation in healthcare. … Learning from failure: the need for independent safety investigation in healthcare.

236. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35721/psn-pdf
     March 28, 2011 - Health Care Failure Mode and Effect Analysis: a useful proactive risk analysis in a pediatric oncology … Health Care Failure Mode and Effect Analysis: a useful proactive risk analysis in a pediatric oncology … https://psnet.ahrq.gov/issue/health-care-failure-mode-and-effect-analysis-useful-proactive-risk-analysis … - pediatric The authors applied the VA's Health Care Failure Mode and Effect Analysis (HFMEA) process … to vincristine  errors and found the tool to be effective in identifying failure.

237. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/48093/psn-pdf
     July 24, 2019 - Failure to report poor care as a breach of moral and professional expectation. … Failure to report poor care as a breach of moral and professional expectation. … https://psnet.ahrq.gov/issue/failure-report-poor-care-breach-moral-and-professional-expectation Culture … https://psnet.ahrq.gov/issue/failure-report-poor-care-breach-moral-and-professional-expectation https

238. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45827/psn-pdf
     January 24, 2018 - Using failure mode and effects analysis to reduce patient safety risks related to the dispensing process … Using Failure mode and Effects Analysis to reduce patient safety risks related to the dispensing process … https://psnet.ahrq.gov/issue/using-failure-mode-and-effects-analysis-reduce-patient-safety-risks-related … - dispensing Failure mode and effect analysis is a tool commonly used to proactively assess the reliability … The authors describe the application of failure mode and effect analysis to identify failure modes in

239. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41297/psn-pdf
     September 19, 2012 - Failure mode and effects analysis: too little for too much? … Failure mode and effects analysis: too little for too much? … the benefits and drawbacks of using failure mode and effects analysis as a prospective risk assessment … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-too-little-too-much https://psnet.ahrq.gov … /issue/failure-mode-and-effect-analysis-reliable https://psnet.ahrq.gov/issue/using-health-care-failure-mode-and-effect-analysis-va-national-center-patient-safetys

240. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34698/psn-pdf
     January 04, 2017 - Using Health Care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective … Using health care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective … https://psnet.ahrq.gov/issue/using-health-care-failure-mode-and-effect-analysis-va-national-center-patient … - safetys The authors describe their adaptation of failure mode and effects analysis, a prospective … Their system, Health Care Failure Mode Effects Analysis (HFMEA), is documented in detail, including